Ophthalmic Formulations Of Cetirizine And Methods Of Use

ABSTRACT

The present invention provides stable topical formulations of cetirizine that provide a comfortable formulation when instilled in the eye and is effective in the treatment of allergic conjunctivitis and/or allergic conjunctivitis. The invention further provides methods of treating allergic conjunctivitis rhinitis, and/or allergic rhinoconjunctivitis in a subject in need of such treatment by topical application of the cetirizine formulations of the invention directly to the eye.

REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. Ser. No. 12/888,117, filed onSep. 22, 2010, which is a continuation in part of U.S. Ser. No.12/724,128, filed Mar. 15, 2010, and claims priority to U.S. ProvisionalApplication No. 61/161,006, filed Mar. 17, 2009 and U.S. ProvisionalApplication No. 61/174,850, filed May 1, 2009, the contents of which areeach hereby incorporated by reference in their entireties.

FIELD OF THE INVENTION

The invention relates to compositions comprising cetirizine, alone or incombination with one or more additional active agents such as a steroidand/or a vasoconstrictor, and methods for using the same for treatingallergic conjunctivitis, rhinitis and/or allergic rhinoconjunctivitis.

BACKGROUND OF THE INVENTION

There exists a need for topical ophthalmic pharmaceutical products toeffectively treat allergic conjunctivitis, rhinitis and/or allergicrhinoconjunctivitis, disorders that presents with both acute allergicsigns and symptoms (i.e., intermittent seasonal or perennial allergy)and late phase inflammatory reactions (i.e., chronic, refractory orpersistent allergy). It has been estimated that 46% (˜70 million) of theadult allergy patients in the United States suffer from both the acuteand late phase conditions of allergic conjunctivitis, whereas only 19%suffer from only acute or late phase allergy, respectively. It isestimated that allergic rhinoconjunctivitis (a combination of ocular andnasal symptoms) may occur in up to 90% of patients with allergies. Theaverage age of allergy sufferers—between 20 and 40 years—coincides withthe average age of the work force and the most productive period of anindividual's life.

Both seasonal and perennial allergic conjunctivitis (ocular allergies)are characterized by ocular itching, redness, lid swelling, chemosis(swelling of the conjunctiva), and tearing. Rhinitis (nasal allergies)manifests as a runny nose (rhinorrhea), sneezing, nasal congestion,nasal itching, and itching of the palate and/or ear. It can be difficultfor a physician to distinguish allergic conjunctivitis from the ocularcomponent of allergic rhinoconjunctivitis because both allergicreactions can occur simultaneously or be triggered by the same types ofstimuli. It is further difficult to distinguish acute allergic symptomsfrom late phase symptoms of allergic conjunctivitis, as each of theseconditions can persist simultaneously or morph back and forth in anygiven individual. The signs and symptoms of allergic conjunctivitis,rhinitis, and allergic rhinoconjunctivitis can significantly impact thequality of life of patients, from social interactions, productivity atwork and school, to the ability to perform visual tasks such as workingon a computer or reading.

Acute symptoms of allergic conjunctivitis are characterized by theclinical signs and symptoms of eye itching, redness, tearing, andswelling. Late phase or allergic inflammation reactions of allergicconjunctivitis include redness, lid swelling and tearing, and in somecases itching, as well as the predominance of congestion in the nose.Acute allergic symptoms are predominantly caused by the activation ofmast cells, which when stimulated by an allergen (pollen, dust, dander)releases a host of substances that produce the signs and symptoms ofallergic conjunctivitis (itching, redness, swelling, and tearing).Histamine is the primary mediator released and stimulates receptors onnerve endings and blood vessels to produce itching and redness. Thereare two histamine receptors that have been identified on the ocularsurface. H1 receptors on nerve endings lead to itching, and H1 and H2receptors on blood vessels lead to dilation of the blood vessels,leading to redness, and leakage of fluid from the vessels into thesurrounding tissue producing swelling. Late phase inflammatory reactionsare mediated by activation of inflammatory cells.

Like allergic conjunctivitis, allergic rhinitis and rhinoconjunctivitisis an allergen-induced, mast cell-mediated response. The reaction istriggered when airborne allergens bind to antibodies attached to thesurface of mast cells in the eye and/or nose. Mast cells, in turn,release chemical mediators, which account for the immediate reaction insensitized individuals exposed to allergen. Some of these mediators,such as histamine, directly affect blood vessels and nerves, leading tothe signs and symptoms of allergic disease. Other released mediatorscause the influx of white blood cells to the site, which leads tosustained symptoms in severe cases and particularly congestion in thenose.

Allergic conjunctivitis, rhinitis, and rhinoconjunctivitis may alsoco-exist with other external ocular conditions and diseases, such as dryeye, urban allergy, or irritations caused by pollutants or other causes.This leads to a compromised tear film, which serves to protect theocular surface from allergens.

Currently available treatments for eye allergy include: drops which canwash allergens off the ocular surface and act as a barrier for the eye(e.g. artificial tears), drugs which block histamine from binding to thehistamine receptors (e.g. antihistamines), drugs that block the releaseof histamine and other substances from the mast cell (e.g. mast cellstabilizers), drugs with multiple modes of action (e.g.antihistamine/mast cell stabilizing agents), corticosteroids, and drugsthat can actively constrict blood vessels thus reducing redness andswelling (e.g. vasoconstrictors). The criteria which may be consideredin evaluating the appropriateness of an agent for a patient include:efficacy at onset of action, duration of action, how well it controlsthe individual signs and symptoms of allergic conjunctivitis, comfort ofthe formulation when instilled in the eye, and safety of the formulationwhen instilled in the eye. The comfort of an ophthalmic product dependson the active pharmaceutical ingredient itself, as well as the nature ofthe formulation and the vehicle that makes up the product. Oralantihistamines have been shown to induce decreased tear production andlead to dryness of the ocular surface, which can exacerbate oculardiscomfort and can make the eye susceptible to irritation by anophthalmic product.

The currently available treatments which contain a single active agent,such as an antihistamine or a mast cell stabilizer, typically providerelief for only acute allergic conjunctivitis and don't address thesigns and symptoms of the late phase inflammatory reactions (i.e.,chronic, refractory, or persistent allergy).

Currently available treatments for rhinitis and allergicrhinoconjunctivitis include eyedrops (for the ocular component), nasalsprays, and systemic oral agents. Currently approved anti-allergyeyedrops are indicated for ocular allergy and nasal sprays are targetedfor nasal allergy. Systemic agents, while they are marketed to treatboth nasal and ocular symptoms, several well controlled clinical trialsconducted to ophthalmic standards have shown that systemicantihistamines are inferior to eyedrops in treating the ocular signs andsymptoms (Spangler et al., Clin. Ther. 25(8), 2245-2267 (2003), are notin fact clinically effective on eye allergy to the level acceptable bythe ophthalmic division at the FDA, and actually have been shown byobjective measures to reduce tear production on the eye by 50%, causingocular dryness (Ousler et al, Ann Allergy Asthma Immunol. November;93(5):460-4 (2004)). Further studies have shown that the concomitant useof an eyedrop and nasal steroid is more effective than a systemic agentin treating the combined ocular and nasal signs and symptoms of allergy(i.e. due to topical ocular therapy being superior than systemic therapyin treating ocular signs and symptoms) (Lanier et al. Clin. Ther. 24(7),1161-1174 (2002)).

Cetirizine hydrochloride is a racemic selective H1 receptor inverseagonist which functions as an antihistamine. It is a major metabolite ofhydroxyzine and a derivative of piperazine. The levorotary enantiomer ofcetirizine is known as levocetirizine. Cetirizine hydrochloride is FDAapproved for oral use and is used as a systemic antihistamine for thetreatment of allergies, hay fever, angioedema, and urticaria. It hasbeen historically difficult to prepare cetirizine as an ophthalmicsolution with satisfactory safety and stability profiles. Cetirizine hasthe disadvantage of forming aggregates in solution at low concentrations(typically less than 1% (w/v)), thereby decreasing the stability as anaqueous solution. Moreover, higher concentrations of cetirizine (1% andabove) are strongly irritating and thus unsuitable for direct ocular ornasal administration. U.S. Pat. No. 5,419,898 addresses these issues byusing a cyclodextrin compound to increase the solubility and stabilityof cetirizine for ophthalmic use. However, a cyclodextrin-free stableophthalmic formulation containing cetirizine as the only activeingredient that is both comfortable in the eye and effective to mitigatethe symptoms of allergic conjunctivitis has never been previouslyachieved. Further it is desired to if possible avoid the need for usinga cyclobetadextran (CBD) as no current ophthalmic products use CBD,there exists potential stability problems over time, andpharmacokinetics may be impacted due to interaction of the activeingredient with the CBD.

There thus exists a need to develop an effective, stable yet comfortableand safe cetirizine formulations for ophthalmic administration for thetreatment of allergic conjunctivitis, rhinitis, (i.e., the acute phase,the late inflammatory phase, or both) and allergic rhinoconjunctivitis.Such formulations for administration directly to the eye would beadvantageous over systemic oral formulations and nasal sprays due tofaster action and avoidance of the side effects associated with systemicadministration.

SUMMARY OF THE INVENTION

The present invention provides comfortable topical ophthalmicformulations for the treatment of both acute and late phase signs ofallergic conjunctivitis, rhinitis, as well as rhinoconjunctivitis whichcontain a combination of ingredients which act synergistically torelieve the signs and symptoms of allergic conjunctivitis and/orrhinitis and/or rhinoconjunctivitis, particularly ocular itching and/ornasal symptoms (e.g., ocular itching, redness, swelling, tearing,running nose, nasal itching, itchy palate, itchy ear, sneezing,nasal/sinus congestion). In contrast to oral administration of allergymedication, topical ophthalmic allergy formulations of the inventionalleviate or reduce drowsiness and systemic exposure to large doses. Inparticular, the formulations described herein provide stableformulations comprising a low concentration of cetirizine suitable forophthalmic use in a comfortable ophthalmic formulation when instilled inthe eye. By suitable for ophthalmic use s meant that the formulation isstable, comfortable, efficacious and safe when instilled in the eye.

The present invention is based on the surprising discovery that stabletopical ophthalmic formulations comprising a low concentration ofcetirizine can be prepared without the use of a cyclodextrin or othersolubilizer compound, that is both comfortable when instilled in the eyeand effective to mitigate the symptoms of allergic conjunctivitis,rhinitis, and/or rhinoconjunctivitis, particularly ocular itching and/ornasal symptoms (e.g., ocular itching, redness, swelling, tearing,running nose, nasal itching, itchy palate, itchy ear, sneezing,nasal/sinus congestion). The invention also provides methods for thetreatment of allergic conjunctivitis, rhinitis, and/orrhinoconjunctivitis in a subject in need of such treatment byadministering a cetirizine formulation of the invention directly to theeye of the subject. Surprisingly, once a day dosing of the lowconcentration cetirizine formulations of the invention is effective tomitigate the symptoms of allergic conjunctivitis, rhinitis, and/orrhinoconjunctivitis, particularly ocular itching and/or nasal symptoms(e.g., ocular itching, redness, swelling, tearing, running nose, nasalitching, itchy palate, itchy ear, sneezing, nasal/sinus congestion). Ofnote, surprisingly the formulations when applied to the eye have asignificant impact on nasal symptoms even though the amount of activepharmaceutical ingredient applied to the eye in the eydrop issignificant less than the amount needed to apply in other marketedformulations of nasal sprays.

The invention also provides stable ophthalmic formulations of cetirizinein combination with one or more active ingredients including but notlimited to a vasoconstrictor such naphazoline or oxymetazoline, and/or asteroid such as fluticasone, or combinations thereof. The combinationformulations of cetirizine are effective in mitigating the signs andsymptoms of both acute and late phase allergic conjunctivitis, rhinitis,and/or rhinoconjunctivitis such as ocular itching, redness, chemosis,tearing and lid swelling, and nasal symptoms such as nasal congestion,nasal itching, sneezing, rhinorrhea, itch palate, and itchy ear, as wellas allergic rhinoconjunctivitis which may contain both ocular and nasalcomponents.

More specifically, the combination formulations of the invention (e.g.,cetirizine and fluticasone) provide a comprehensive treatment benefitfor both acute and late phase reactions of allergic conjunctivitis,rhinitis, and rhinoconjunctivitis that cannot be achieved by the use ofa single anti-allergic, or other active agent, alone. Antihistamines andmast cell stabilizers such as cetirizine do not effectively block allallergic and pro-inflammatory mediators from the mast cell. Cetirizine,and other antihistamines and mast cell stabilizers, effectively masksitching but has minimal effects on redness, tearing, swelling andinflammation. However, when cetirizine is combined with another activeagent which can halt the transcription and production of inflammatorymediators and down-regulate the production of anti-inflammatorymediator, such as a steroid (e.g., fluticasone), treatment of the signsand symptoms of acute and late phase allergic conjunctivitis ((i.e., theaggregate disease), rhinitis, and rhinoconjunctivitis is achieved.Likewise, such combination formulations provide a comprehensivetreatment benefit for rhinitis and rhinoconjunctivitis that cannot beachieved by the use of a single anti-allergic, or other active agentalone, for these same reasons.

In one particular embodiment, the cetirizine formulation of theinvention comprises a stable ophthalmic formulation of cetirizine as theonly active ingredient at a concentration of 0.01% to 1.0% (w/v),preferably 0.05% to 0.5% (w/v), more preferably 0.08% to 0.12% (w/v) orany specific value within said ranges. Preferably, cetirizine is in theform of cetirizine hydrochloride or dihydrochloride. Surprisingly, thestable cetirizine formulation is achieved without the use of acyclodextrin, or other solubilizing compound, which were described asbeing required in U.S. Pat. No. 5,419,898.

In another particular embodiment, the invention provides a stableophthalmic formulation of cetirizine in combination with fluticasone.Preferably, cetirizine is in the form of cetirizine hydrochloride ordihydrochloride. In certain embodiments, cetirizine is present in theformulation at a concentration of 0.05% to 1.0% (w/v), or any specificvalue within said range. For example, cetirizine is formulated at aconcentration of 0.050% to 0.075%, 0.075% to 0.1%, 0.1% to 0.25%, 0.25%to 0.50%, 0.50% to 0.75%, or 0.75% to 1.0% (w/v), or any specific valuewithin said ranges). In particular embodiments, cetirizine is formulatedat a concentration of 0.05%, 0.06%, 0.07% 0.08, %, 0.09%, 0.1%, 0.12%,0.13%, 0.14%, 0.15%, 0.2%, 0.25%, 0.3%, 0.35%, 0.4%, 0.45%, 0.5%, 0.6%,0.7%, 0.8%, 0.9%, or 1.0% (w/v). In certain embodiments, fluticasone ispresent in the formulation at a concentration of 0.001% to 1.0% (w/v),or any specific value within said range. Preferably, fluticasone ispresent in the formulation at a concentration of 0.001% and 0.2% (w/v),or any specific value within said range. For example, fluticasone isformulated at a concentration of 0.001%, 0.002%, 0.003%, 0.004%, 0.005%,0.006%, 0.007%, 0.008%, 0.009%, 0.01%, 0.015%, 0.025%, or 0.2% (w/v). Ina particular embodiment, cetirizine is present in the formulation at aconcentration of 0.1% (w/v) and fluticasone is present in theformulation at a concentration of 0.005% (w/v). In a another particularembodiment, cetirizine is present in the formulation at a concentrationof 0.08% to 0.12% (w/v) and fluticasone is present in the formulation ata concentration of 0.004% to 0.006% (w/v). In another particularembodiment, cetirizine is present in the formulation at a concentrationof 0.25% (w/v) and fluticasone is present in the formulation at aconcentration of 0.01% (w/v). The stable cetirizine/fluticasoneformulation is achieved without the use of a cyclodextrin, or othersolubilizing compound. The cetirizine alone, and combinationformulations of the invention (e.g., cetirizine/fluticasone) are stableand comfortable upon instillation in the eye. Surprisingly, thecetirizine/fluticasone formulations of the invention do not increaseintraocular pressure in the eye after repeated use (e.g., after 14 days)and that it was possible to identify a clinically effective dose whenused once daily (QD). As such the cetirizine combination formulations ofthe invention are safe for ocular use.

In certain embodiments, the cetirizine alone and cetirizine combinationformulations of the invention are formulated in a vehicle comprising 1%Polyethylene Glycol 400, NF; 0.2% Dibasic Sodium Phosphate, Anhydrous,USP; 0.25% Hypromellose, USP; 0.1% Polysorbate 80, NF; 1.2% to 1.8%Glycerin (or any specific value within said range), USP; 0.025% EdetateDisodium, USP; 0.01% Benzalkonium Chloride, NF (pH 7.0).

In some embodiments, the stable ophthalmic cetirizine formulations ofthe invention comprise a tear substitute. In particular embodiments, thetear substitute is hydroxypropylmethyl cellulose (Hypromellose or HPMC).According to some embodiments, the concentration of HPMC ranges fromabout 0.1% to about 2% w/v, or any specific value within said range.According to some embodiments, the concentration of HPMC ranges fromabout 0.5% to about 1% w/v, or any specific value within said range. Ina preferred embodiments, the concentration of HPMC ranges from about0.1% to about 1.0% w/v, or any specific value within said range (e.g.,0.1-0.2%, 0.2-0.3%, 0.3-0.4%, 0.4-0.5%, 0.5-0.6%, 0.6-0.7%, 0.7-0.8%,0.8-0.9%, 0.9-1.0%; about 0.2%, about 0.21%, about 0.22%, about 0.23%,about 0.24%, about 0.25%, about 0.26%, about 0.27%, about 0.28%, about0.29%, about 0.30%, about 0.70%, about 0.71%, about 0.72%, about 0.73%,about 0.74%, about 0.75%, about 0.76%, about 0.77%, about 0.78%, about0.79%, about 0.80%, about 0.81%, about 0.82%, about 0.83%, about 0.84%,about 0.85%, about 0.86%, about 0.87%, about 0.88%, about 0.89%, orabout 0.90%).

In another particular embodiment the tear substitute is carboxymethylcellulose (CMC). According to some embodiments, the concentration of CMCranges from about 0.1% to about 2% w/v, or any specific value withinsaid range. According to some embodiments, the concentration of CMCranges from about 0.1% to about 1% w/v, or any specific value withinsaid range. In a preferred embodiments, the concentration of CMC rangesfrom about 0.7% to about 0.9% w/v, or any specific value within saidrange (i.e., about 0.70%, about 0.71%, about 0.72%, about 0.73%, about0.74%, about 0.75%, about 0.76%, about 0.77%, about 0.78%, about 0.79%,about 0.80%, about 0.81%, about 0.82%, about 0.83%, about 0.84%, about0.85%, about 0.86%, about 0.87%, about 0.88%, about 0.89%, or about0.90%).

In yet another particular embodiment, the stable ophthalmic cetirizineformulations of the invention comprise a polymeric, mucoadhesivevehicle. Examples of mucoadhesive vehicles suitable for use in themethods or formulations of the invention include but are not limited toaqueous polymeric suspensions comprising one or more polymericsuspending agents including without limitation dextrans, polyethyleneglycol, polyvinylpyrolidone, polysaccharide gels, Gelrite®, cellulosicpolymers, and carboxy-containing polymer systems. In a particularembodiment, the polymeric suspending agent comprises a crosslinkedcarboxy-containing polymer (e.g., polycarbophil). In another particularembodiment, the polymeric suspending agent comprises a polyethyleneglycol (PEG). Examples of cross-linked carboxy-containing polymersystems suitable for use in the topical stable ophthalmic cetirizineformulations of the invention include but are not limited to NoveonAA-1, Carbopol®, and/or DuraSite® (InSite Vision).

Optionally, the formulations of the invention contain a preservative. Inparticular embodiments the preservative is benzalkonium chloride or aderivative thereof (e.g., Polyquad®), sorbate, sodium perborate, or astabilized oxychloro complex (e.g., Purite®).

According to some embodiments, the ophthalmic formulations of thepresent invention has a viscosity that ranges from about 30 to about 150centipoise (cpi), preferably about 50 to about 120 cpi, even morepreferably about 60 to about 115 cpi (or any specific value within saidranges). According to preferred embodiments, the ophthalmic formulationsof the present invention has a viscosity that ranges from about 60 toabout 80 cpi, or any specific value within said range (i.e., about 60cpi, about 61 cpi, about 62 cpi, about 63 cpi, about 64 cpi, about 65cpi, about 66 cpi, about 67 cpi, about 68 cpi, about 69 cpi, about 70cpi, about 71 cpi, about 72 cpi, about 73 cpi, about 74 cpi, about 75cpi, about 76 cpi, about 77 cpi, about 78 cpi, about 79 cpi, or about 80cpi).

The invention also provides methods of treating and preventing thesymptoms of allergic conjunctivitis by administering a stable cetirizineformulation of the invention (i.e., cetirizine alone or in combinationwith an additional active agent such as a steroid (e.g., fluticasone) ora vasoconstrictor (e.g., naphazoline or oxymetazoline) directly to theeye of a subject in need of such treatment or prevention. Theformulation of the invention is administered once a day (q.d.). Once aday administration is particularly advantageous it limits drug exposureand therefore reduced unwanted side effects. In certain embodiments, themethods of the invention (i.e., administration of a formulation of theinvention directly to the eye) are also effective to treat nasalsymptoms associated with allergic conjunctivitis, rhinitis, andrhinoconjunctivitis. The invention also provides methods of treating andpreventing the symptoms of allergic rhinoconjunctivitis by administeringa stable cetirizine formulation of the invention (i.e., cetirizine aloneor in combination with an additional active agent such as a steroid(e.g., fluticasone) or a vasoconstrictor (e.g., naphazoline oroxymetazoline) directly to the eye of a subject in need of suchtreatment or prevention. The active drug of the eyedrop then drainsthrough the nasolacrimal duct into the nasal mucosal tissue to exertsurprising effects. By providing a treatment option in eye drop form,the present invention will improve quality of life in patients withallergic conjunctivitis, rhinoconjunctivitis, and rhinitis (See e.g.,Berger et al., Ann. Allergy Asthma Immunol. October 95(4), 361-71(2005).

The invention further provides kits comprising a pharmaceuticalcomposition of cetirizine formulated for ophthalmic use and instructionsfor such use. Other features and advantages of the invention will becomeapparent from the following detailed description and claims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a line graph depicting the efficacy of a 0.1% cetirizineformulation reducing of ocular itching as compared to a vehicle control.The mean ocular itching score (scale of 0 to 4) is shown at 0, 3, 5, and7 minutes after conjunctival challenge with allergen; FIG. 1B is a linegraph depicting the efficacy of a 0.1% cetirizine formulation reducingconjunctival redness as compared to a vehicle control

FIG. 2 is a line graph depicting the comfort profile of a 0.1%cetirizine formulation upon instillation in the eye as compared to avehicle control. The comfort of the formulation is indicated on asubjective scale of 0 to 10 (0=very comfortable; >4=uncomfortable;10=very uncomfortable). The mean drop comfort score is shown at 0, 1, 2minutes after addition of a drop of the cetirizine formulation of theinvention.

FIGS. 3A and 3B depict a study design (screening and evaluation) fortesting the efficacy of Fluticasone 0.001%, 0.005% and 0.01% as comparedto vehicle in reducing ocular and nasal symptoms of ocular allergy in anallergic conjunctivitis model.

FIG. 4 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing ocular itchingassessed on a scale of 0 (no itching) to 4 (severe itching) over time.

FIG. 5 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing conjunctivalredness, assessed on a scale of 0 (no redness) to 4 (severe redness)over time.

FIG. 6 is line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing lid swelling,assessed on a scale of 0 (no swelling) to 3 (severe swelling) over time.

FIG. 7 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing nasal congestion,assessed on a scale of 0 (no congestion) to 4 (severe congestion) overtime.

FIG. 8 is a bar graph summarizing the results shown in FIGS. 3-7.

FIG. 9 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing ciliary redness,assessed on a scale of 0 (no redness) to 4 (severe redness) over time.

FIG. 10 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing episcleral redness,assessed on a scale of 0 (no redness) to 4 (severe redness) over time.

FIG. 11 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing chemosis, assessedon a scale of 0 (none) to 4 (severe) over time.

FIG. 12 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing watery eyes,assessed on a scale of 0 (none) to 4 (severe) over time.

FIG. 13 is a bar graph summarizing the results shown in FIGS. 9-11.

FIG. 14 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing rhinorrhea, assessedon a scale of 0 (none) to 4 (severe) over time.

FIG. 15 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing ear or palatepruritis, assessed on a scale of 0 (none) to 4 (severe) over time.

FIG. 16 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle in reducing nasal pruritis,assessed on a scale of 0 (none) to 4 (severe) over time.

FIG. 17 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle on total nasal score, assessedon a scale of 0 (no nasal symptoms) to 16 (multiple nasal symptoms) overtime.

FIG. 18 is a bar graph summarizing the results shown in FIGS. 14-17.

FIG. 19 is a line graph comparing the efficacy of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle on peak nasal inspiratory flow(PNIF).

FIG. 20 a line graph comparing the drop comfort of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle, assessed on a scale of 0(extremely comfortable) to 10 (extremely uncomfortable) over time atVisit 2.

FIG. 21 a line graph comparing the drop comfort of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle, assessed on a scale of 0(extremely comfortable) to 10 (extremely uncomfortable) over time atVisit 3.

FIG. 22 is a chart summarizing the incidence of adverse eventsassociated with instillation of Fluticasone 0.001%, 0.005% and 0.01% inthe eye.

FIG. 23 is a bar graph summarizing the effects of Fluticasone 0.001%,0.005% and 0.01% as compared to vehicle on intraocular pressure.

FIG. 24 is a bar graph summarizing the effects of a 0.1%cetirizine/0.005% fluticasone formulation (low dose) and a 0.25%cetirizine/0.01% fluticasone formulation (high dose) on conjunctivalhyperemia, chemosis, discharge, and lid swelling after three days ofdosing, as compared to 0.1% cetirizine alone, 0.005% fluticasone alone,a leading commercial antihistamine for treating allergic conjunctivitis(Pataday®; olopatadine 0.2%), a commercially available steroid (PredForte®; prednisolone acetate 1%) and a vehicle control.

FIG. 25 is a bar graph summarizing the effects of a 0.1%cetirizine/0.005% fluticasone formulation (low dose) and a 0.25%cetirizine/0.01% fluticasone formulation (high dose) on conjunctivalhyperemia, chemosis, discharge, and lid swelling after three days ofdosing, as compared to 0.1% cetirizine alone, 0.005% fluticasone alone,and vehicle control.

FIG. 26 is a bar graph summarizing the effects of a 0.1%cetirizine/0.005% fluticasone formulation (low dose) on conjunctivalhyperemia, chemosis, discharge, and lid swelling after three days ofdosing, as compared to 0.1% cetirizine alone, 0.005% fluticasone alone,and vehicle control.

FIG. 27 is a bar graph summarizing the sum of clinical exam scores for a0.1% cetirizine/0.005% fluticasone formulation (low dose) and a 0.25%cetirizine/0.01% fluticasone formulation (high dose), 0.1% cetirizinealone formulation, 0.005% fluticasone alone formulation, an olopatadine0.2% formulation, a prednisolone acetate 1% formulation and a vehiclecontrol.

FIG. 28 is a bar graph summarizing the sum of clinical exam scores for a0.1% cetirizine/0.005% fluticasone formulation (low dose) and a 0.25%cetirizine/0.01% fluticasone formulation (high dose), 0.1% cetirizinealone formulation, 0.005% fluticasone alone formulation, and a vehiclecontrol.

FIG. 29 is a line graph depicting the comfort profile of a 0.1%cetirizine/0.005% fluticasone formulation (low dose) and a 0.25%cetirizine/0.01% fluticasone formulation (high dose) upon instillationin the eye as compared to controls. The comfort of the formulation isindicated on a subjective scale of 0 to 10 (0=very comfortable; 10=veryuncomfortable).

FIG. 30 is a line graph depicting the mean itching score at visit 3 postCAC for a 0.1% cetirizine/0.005% fluticasone formulation (low dose),0.1% cetirizine alone formulation, 0.005% fluticasone alone formulation,and a vehicle control.

FIG. 31 is a line graph depicting the mean itching score at visit 4Apost CAC for a 0.1% cetirizine/0.005% fluticasone formulation (lowdose), 0.1% cetirizine alone formulation, 0.005% fluticasone aloneformulation, and a vehicle control.

FIG. 32 is a line graph depicting the mean itching score at visit 4Bpost CAC for a 0.1% cetirizine/0.005% fluticasone formulation (lowdose), 0.1% cetirizine alone formulation, 0.005% fluticasone aloneformulation, and a vehicle control.

FIG. 33 is a line graph depicting the mean conjunctival redness score atvisit 4A post CAC for a 0.1% cetirizine/0.005% fluticasone formulation(low dose), 0.1% cetirizine alone formulation, 0.005% fluticasone aloneformulation, and a vehicle control.

FIG. 34 is a line graph depicting the mean conjunctival redness score atvisit 4B post CAC for a 0.1% cetirizine/0.005% fluticasone formulation(low dose), 0.1% cetirizine alone formulation, 0.005% fluticasone aloneformulation, and a vehicle control.

FIG. 35 are tables showing comparison of 0.1% cetirizine/0.005%Fluticasone with Pataday and Alcaftadine treatment on mean itching scoreat visit 3 and 4A post CAC.

FIG. 36 is a bar chart depicting interocular pressure (IOP) at visit 1and visit 4 for a 0.1% cetirizine/0.005% fluticasone formulation (lowdose) 0.1% cetirizine alone formulation, 0.005% fluticasone aloneformulation, and a vehicle control.

FIG. 37 are bar charts depicting the comfort profile of 0.1%cetirizine/0.005% fluticasone formulation (low dose), 0.1% cetirizinealone formulation, 0.005% fluticasone alone formulation, and a vehiclecontrol. The comfort of the formulation is indicated on a subjectivescale of 0 to 10 (0=very comfortable; 10=very uncomfortable).

FIG. 38 is a bar chart depicting interocular pressure (IOP) distributionby treatment group. Subjects were treated with 0.1% cetirizine/0.005%fluticasone formulation (low dose), 0.1% cetirizine alone formulation,0.005% fluticasone alone formulation, and a vehicle control.

FIG. 39 is a bar chart depicting interocular pressure (IOP) elevationupon treatment with Alrex.

FIG. 40 are tables showing comparison of 0.1% cetirizine/0.005%Fluticasone with Vehicle treatment on mean ocular itching treatmentdifferences by visit.

FIG. 41 are tables comparison of 0.1% cetirizine/0.005% Fluticasone withvehicle on mean conjunctival redness treatment differences by visit.

FIG. 42 are tables showing comparison of 0.1% cetirizine/0.005%Fluticasone with individual component treatment on mean ocular itchingtreatment differences by visit

FIG. 43 are tables comparison of 0.1% cetirizine/0.005% Fluticasone withindividual component on mean conjunctival redness treatment differences(Active-Vehicle) by visit.

FIG. 44 are tables showing of 0.1% cetirizine/0.005% Fluticasone withVehicle: ciliary redness treatment differences by visit.

DETAILED DESCRIPTION OF THE INVENTION

The invention is based in part on the discovery that low concentrationsof cetirizine (i.e., less than 1%) can be prepared as a stableophthalmic formulation, without the use of a cyclodextrin or othersolubilizing compound. Such formulations are comfortable and safe forocular use and effective at reducing the symptoms of allergicconjunctivitis, rhinitis, and/or allergic rhinoconjunctivitis,particularly ocular itching, redness, swelling, and tearing and/or nasalsymptoms (e.g., itchy, running nose, sneezing, nasal/sinus congestion,itchy palate, itchy ear). The invention is further based upon thesurprising discovery that formulation of 0.01% cetirizine and 0.005%Fluticasone provide a greater reduction of the symptoms of allergicconjunctivitis, rhinitis, and/or allergic rhinoconjunctivitis,particularly ocular itching, redness, swelling, and/or nasal symptoms(e.g., itchy, running nose, sneezing, nasal/sinus congestion) thaneither component when administered alone at the same concentration or athigher concentrations when administered together. More surprisingly, thecombination when administered to the eye also provides reduction ofnasal symptoms at least to the level seen with much higher doses inexisting marketed nasal products.

The historical difficulty in preparing cetirizine as an ophthalmicsolution with satisfactory safety and stability profiles is wellrecognized in the art due to the fact that cetirizine aggregates insolution at low concentrations, and is highly irritating to the ocularsurface at high concentrations, being a strong acid. Without intendingto be bound by any theory, it was believed necessary to reduce thepossibility of salt formation and metal based degradation in order toarrive at a stable formulation. As such, the addition of counter ions ormetal based buffers that could promote salt formation, precipitation, ormetal based degradation were minimized or excluded from the cetirizineformulations of the invention. Furthermore, it was discovered that thepH could be adjusted to approximately 7.0 with no adverse effects onstability, to improve the comfort of the formula.

The invention features novel topical ophthalmic formulations comprisingan effective amount of cetirizine, or a pharmaceutically acceptable saltthereof, in a pharmaceutically acceptable carrier. Pharmaceuticallyacceptable cetirizine salts include cetirizine hydrochloride orcetirizine dihydrochloride. In particular embodiments, the inventionprovides stable ophthalmic formulations of cetirizine as the only activeagent in the formulations. The invention also features ophthalmicformulations of cetirizine in combination with one or more additionalactive ingredients selected from oxymetazoline, naphazoline andfluticasone. In a preferred embodiment, the invention features anophthalmic formulation of 0.1% cetirizine and 0.005% Fluticasone. Suchpreferred combination formulations are effective in further mitigatingthe acute and late phase signs and symptoms of allergic conjunctivitis,rhinitis, and rhinoconjunctivitis, such as ocular itching, redness,chemosis, lid swelling and also nasal symptoms. Such formulations arealso effective in mitigating the signs and symptoms ofrhinoconjunctivitis, such as runny nose (rhinorrhea), sneezing,nasal/sinus congestion, nasal itching, itchy palate, itchy ear, and red,watery, swollen, and/or itchy eyes.

The comfort, safety, efficacy, solubility, and stability of theophthalmic formulations of the invention could not have been predictedby one skilled in the art. Many antihistamines have been developed overthe years by various companies for different indications. However, notall of these can be formulated or are effective as an eyedrop. Likewisenot all antihistamines have the same duration of action. For example thepotent antihistamine levocabastine has a duration of 2-4 hours; recentlyapproved bepotastine (Bepreve®-ISTA), indicated for twice daily dosing,has an 8 hour duration; olopatadine 0.1% (Patanol®) indicated for twicedaily dosing, has an 8 hour duration; and olopatadine 0.2% (Pataday®),indicated for once daily dosing, has a 16 hour duration of action.Therefore the efficacy is not predictable. In one study (Berdy et al,1990), a panel of antihistamines were screened yet only a few weresuitable for the eye based on comfort, formulation, irritation, andefficacy. As evidenced by Berdy et al., one skilled in the art could nothave predicted which of the antihistamines would be ideal for ocular useor for treating ocular allergy. The invention is based, in part, uponthe surprising and unpredictable discovery that an antihistamine and asteroid, (in particular of cetirizine and fluticasone) when combined,act synergistically to treat both the acute and late phase reactions ofallergic conjunctivitis, rhinitis as well as allergicrhinoconjunctivitis.

In some embodiment, the cetirizine formulations of the inventioncomprise one or more tear substitute components. The cetirizinecomponent provides relief of the symptoms of allergic conjunctivitis,and the one or more tear substitute component provides ocular surfaceprotection via enhancement of the tear film (as evident by increasedtear film break up time), and can act to enhance dwell time on theocular surface thus increasing duration of activity. An effective amountof such formulations may be used to treat and/or prevent signs andsymptoms associated with acute and/or late phase allergicconjunctivitis, rhinitis, and/or rhinoconjunctivitis, urban allergy, dryeye and/or general eye irritation, and can also be used to treat anothereye disorder if it contains a drug for that disorder. An effectiveamount of such formulations may also be used to treat and/or preventsigns and symptoms of allergic rhinoconjunctivitis. Such formulationsprovide a comfortable ophthalmic formulation when instilled in the eyeand have enhanced efficacy and/or duration of action over formulationsof cetirizine that are not combined with such other agents.

The superior efficacy of the combination cetirizine/tear substituteformulations is attributed to, among other things, the synergisticeffect of the combination of ingredients in them. The combination ofcetirizine and tear substitute, act synergistically to provide a longerdwell time of the cetirizine on the ocular surface, thus increasingduration and efficacy of action, and to prolong the integrity of thetear film thereby providing protection of the ocular surface (e.g., byincreasing the tear film break up time and/or the Ocular ProtectionIndex). As such, the compositions of the invention are comfortable uponinstillation into the eye, and may be used for relief of acute orchronic allergic conjunctivitis, dry eye, rhinitis, andrhinoconjunctivitis, or urban allergy, and are particularly suitable forboth intermittent and long term use.

Synergy, in general, may be defined as two or more agents workingtogether to produce a result not obtainable by any of the agentsindependently. In particular in the context of the present inventionsynergy is a result greater than the results of the individual agents atthe same concentration as in the combination. Synergy may also bedefined as clinical superiority of the two or more agent compared to theindividual agents alone. By clinical superiority is meant that thedifference between the combination treatment and treatment with theindividual agents alone at the same concentration is clinically orstatistically significant. Clinical significance is meant that thetreatment provides a clinical benefit that is a reduction of a sign orsymptom of the disease or disorder being treated.

Formulations

In the context of this patent all concentrations are given for thecetirizine free base. The concentration for the cetirizine salt (e.g.cetirizine hydrochloride or dihydrochloride) can be calculated bymultiplying the free base concentration by 1.188. e.g. 0.1% cetirizinefree base is equivalent to 0.1188% cetirizine dihydrochloride salt(0.1%×1.188=0.11881%).

Preferably, the ophthalmic formulations according to the presentinvention are formulated as solutions, suspensions, ointments, gels,emulsions, oils, and other dosage forms for topical administration.Aqueous solutions are generally preferred, based on ease of formulation,as well as a patient's ability to easily administer such compositions bymeans of instilling one to two drops of the solutions in the affectedeyes. However, the compositions may also be suspensions, viscous orsemi-viscous gels, or other types of solid or semisolid compositions orsustained release devices or mechanisms that are placed in or around theeye. In one embodiment, the cetirizine formulations of the invention areaqueous formulations. The aqueous formulations of the invention aretypically more than 50%, preferably more than 75%, and most preferablymore than 90% by weight water. Preferably, the aqueous formulation doesnot contain a cyclodextrin or other solubilizer compound becausecyclobetadextran may in some cases impact stability, or pharmacokineticsof the drug. Stable aqueous formulations of cetirizine are achieved byminimizing/excluding the addition of counter ions or metal based buffersthat could promote salt formation, precipitation, or metal baseddegradation. In another embodiment, the cetirizine formulations arelyophilized formulations.

Active Agents

Cetirizine is the primary active agent in the ophthalmic formulations ofthe present invention, and in certain embodiments, the only active agentin the formulations of the invention. In certain embodiments of theinvention, cetirizine, or a pharmaceutically acceptable salt thereof, isformulated at a concentration of 0.01% to 1.0% (w/v). Preferably,cetirizine is in the form of cetirizine hydrochloride ordihydrochloride. In certain embodiments, cetirizine is formulated at aconcentration of 0.05% to 0.075%, 0.075% to 0.1%, 0.08% to 0.12%, 0.1%to 0.25%, 0.25% to 0.50%, 0.50% to 0.75%, or 0.75% to 1.0% (w/v). Inparticular embodiments, cetirizine is formulated at a concentration of0.05% to 1.0% (w/v), or any specific value within said range. Forexample, cetirizine is formulated at a concentration of 0.05%, 0.06%,0.07%, 0.08%, 0.09%, 0.1%, 0.12%, 0.13%, 0.14%, 0.15%, 0.16%, 0.17%,0.18%, 0.19% 0.2%, 0.25%, 0.3%, 0.35%, 0.4%, 0.45%, 0.5%, 0.6%, 0.7%,0.8%, 0.9%, or 1.0% (w/v). (w/v). In one embodiment, the cetirizineformulation of the invention comprises cetirizine hydrochloride ordihydrochloride as the only active ingredient at a concentration of0.01% to 1.0% (w/v), preferably 0.05% to 0.5% (w/v), more preferably0.1% to 0.25% (w/v), most preferably 0.08% to 0.12% (w/v) (or anyspecific value within said ranges).

Cetirizine may be formulated with other active agents as describedherein. For example, cetirizine may be formulated with one or moreadditional anti-allergic agents. The term “anti-allergenic agent” refersto a molecule or composition that treats allergic conjunctivitis,rhinitis and/or rhinoconjunctivitis or reduces a symptom of allergicconjunctivitis, rhinitis and/or rhinoconjunctivitis. The term “allergicconjunctivitis” refers to any allergic disease of the eye, e.g.,seasonal/perennial allergic conjunctivitis, vernal keratoconjunctivitis,giant papillary conjunctivitis, perennial allergic conjunctivitis andatopic keratoconjunctivitis. The signs and symptoms of ocular allergiesinclude chemosis, eye itching, tearing, redness and swelling, and mayalso co-exist with nasal symptomotology. The term “rhinitis” refers toany allergic or non-allergic disorder of the nose, e.g. seasonal orperennial allergic rhinitis, vasomotor rhinitis, and the signs andsymptoms include nasal itching, sneezing, rhinorrhea, nasal congestion,itchy palate, itchy ear. The term “allergic rhinoconjunctivitis” refersto a combination of nasal and ocular symptoms characterized byinflammation of the lining of the tissue of the eyes and nose due to anallergy with or without infection, causing nasal discharge, mucus,sneezing, irritation, swollen, and red, watery, itchy eyes. Non-limitingexamples of anti-allergic agents include “antihistamines” or drugs whichblock histamine from binding to the histamine receptors, “mast cellstabilizers” or drugs that block the release of histamine and othersubstances from the mast cell, “drugs with multiple modes of action” ordrugs that are antiallergenic agents having multiple modes of action(e.g. drugs that are antihistamines and mast cell stabilizers, drugswith antihistamine, mast cell stabilizing and anti-inflammatoryactivity, etc.), steroids, and nonsteroidal anti-inflammatory drugs or“NSAIDs.”

In certain embodiments, cetirizine is formulated with one or moreadditional active agents selected from a mast cell stabilizer such asnedocromil, iodoxamide, cromolyn, or cromolyn sodium; a non-steroidalanti-inflammatory drug (“NSAID”) such as diclofenac or ketorolactromethamine, bromfenac, or nepafenac; a vasoconstrictor such asnaphazoline, tetrahydrozoline or oxymetazoline; a topical steroid suchas fluticasone, beclomethasone, budesonide, diflorasone,triaminicinolone, clobetasol, difluprednate, prednisolone,dexamethasone, halobetasol, or mometasone; an antihistamine such asantazoline, astemizole, alcaftadine, azelastine, bepotastine, bilastine,brompheniramine, chlorpheniramine, clemastine, desloratidine,dexbrompheniramine, diphenhydramine, doxylamine, ebastine, emedastine,epinastine, fexofenadine, hydroxyzine, ketotifen, levocabastine,levocetirizine, loratidine, mequitazine, mizolastine, olopatadine,oxatomide, phenindamine, pheniramine, pyrilamine, terfenidine, andtriprolidine; or an alpha-adrenergic agonist such as epinephrine,fenoxazoline, indanazoline, naphazoline, oxedrine, phenylephrine,tefazoline, tetryzoline, tramazoline, tymazoline, oxymetazoline, orxylometazoline.

In certain embodiments, cetirizine is formulated with one or moreadditional active agents such as a vasoconstrictor (e.g., naphazoline oroxymetazoline), or a steroid (e.g., fluticasone).

Naphazoline (in the hydrochloride form) is the common name for2-(1-naphthylmethyl)-2-imidazoline hydrochloride. It is asympathomimetic agent with marked alpha adrenergic activity. It is avasoconstrictor with a rapid action in reducing swelling when applied tomucous membrane. It acts on alpha-receptors in the arterioles of theconjunctiva to produce constriction, resulting in decreased congestion.Oxymetazoline is a selective alpha-1 agonist and partial alpha-2 agonisttopical decongestant, used in the form of oxymetazoline hydrochloride incommercially available nasal sprays. Oxymetazoline has sympathomimeticproperties, and thus constricts the blood vessels of the nose andsinuses via activation of alpha-2 adrenergic receptors. Fluticasone is apotent synthetic corticosteroid often prescribed as treatment for asthmaand allergic rhinitis.

In certain embodiments, cetirizine is formulated at a concentration offrom 0.05% to 0.50% (w/v), in combination with naphazoline at aconcentration of from 0.01% to 0.5% (w/v), preferably 0.01% to 0.1%(w/v), preferably 0.05% to 0.1% (w/v), more preferably 0.09% to 0.1%(w/v). In particular embodiments, cetirizine is formulated at aconcentration of 0.01%, 0.05%, 0.06%, 0.07%, 0.08%, 0.09%, 0.10%, 0.15%,0.20%, 0.25%, 0.30%, 0.35%, 0.45%, or 0.50% (w/v) in combination withnaphazoline at a concentration of 0.01%, 0.02%, 0.03%, 0.04%, 0.05%,0.06% 0.07%, 0.08%, 0.09% or 0.10% (w/v).

In certain embodiments, cetirizine is formulated at a concentration offrom 0.05% to 0.50% (w/v) in combination with oxymetazoline at aconcentration of from 0.01% to about 0.2% (w/v), preferably 0.01% to0.1% (w/v), more preferably 0.03% to 0.05% (w/v). In particularembodiments, cetirizine is formulated at a concentration of 0.05%,0.06%, 0.07%, 0.08%, 0.09%, 0.10%, 0.15%, 0.20%, 0.25%, 0.30%, 0.35%,0.45%, or 0.50% (w/v) in combination with oxymetazoline at aconcentration of 0.01%, 0.02%, 0.03%, 0.04%, 0.05%, 0.06%, 0.07% 0.09%or 0.10% (w/v).

In certain embodiments, cetirizine is formulated at a concentration offrom 0.05% to 0.50% (w/v) in combination with fluticasone at aconcentration of from 0.001% to 1.0% (w/v), preferably 0.001% to 0.2%(w/v), or any specific value within said ranges. In particularembodiments, cetirizine is formulated at a concentration of 0.05%,0.06%, 0.07%, 0.08%, 0.09%, 0.10%, 0.12% 0.15%, 0.20%, 0.25%, 0.30%,0.35%, 0.45%, or 0.50% (w/v) in combination with fluticasone at aconcentration of 0.001%, 0.002%, 0.003%, 0.004%, 0.005%, 0.006%, 0.007%,0.008%, 0.009%, 0.01%, 0.015%, 0.05%, 0.1%, 0.2%, 0.5%, or 1% (w/v). Ina particular embodiment, the cetirizine is present in the formulation ata concentration of 0.25% (w/v) and the fluticasone is present in theformulation at a concentration of 0.01% (w/v). In another particularembodiment, the cetirizine is present in the formulation at aconcentration of 0.1% (w/v) and the fluticasone is present in theformulation at a concentration of 0.005% (w/v). In another particularembodiment, the cetirizine is present in the formulation at aconcentration of 0.08% to 0.12% (w/v) and the fluticasone is present inthe formulation at a concentration of 0.004% to 0.006% (w/v).

In certain embodiments, the viscosity of the cetirizine formulations ofthe invention (i.e. cetirizine alone or in combination with anadditional active agent) ranges from 1-50 centipoise (cpi), or anyspecific value within said range. In a particular embodiment, theviscosity of the cetirizine formulations of the invention range from5-30 cpi, preferably 10-20 cpi.

Excipients

In some embodiments, the cetirizine formulations of the inventioncomprise one or more pharmaceutically acceptable excipients. The termexcipient as used herein broadly refers to a biologically inactivesubstance used in combination with the active agents of the formulation.An excipient can be used, for example, as a solubilizing agent, astabilizing agent, a surfactant, a demulcent, a viscosity agent, adiluent, an inert carrier, a preservative, a binder, a disintegrant, acoating agent, a flavoring agent, or a coloring agent. Preferably, atleast one excipient is chosen to provide one or more beneficial physicalproperties to the formulation, such as increased stability and/orsolubility of the active agent(s). A “pharmaceutically acceptable”excipient is one that has been approved by a state or federal regulatoryagency for use in animals, and preferably for use in humans, or islisted in the U.S. Pharmacopia, the European Pharmacopia or anothergenerally recognized pharmacopia for use in animals, and preferably foruse in humans.

Further examples of excipients include certain inert proteins such asalbumins; hydrophilic polymers such as polyvinylpyrrolidone; amino acidssuch as aspartic acid (which may alternatively be referred to asaspartate), glutamic acid (which may alternatively be referred to asglutamate), lysine, arginine, glycine, and histidine; fatty acids andphospholipids such as alkyl sulfonates and caprylate; surfactants suchas sodium dodecyl sulphate and polysorbate; nonionic surfactants such assuch as TWEEN®, PLURONICS®, or a polyethylene glycol (PEG) designated200, 300, 400, or 600; a Carbowax designated 1000, 1500, 4000, 6000, and10000; carbohydrates such as glucose, sucrose, mannose, maltose,trehalose, and dextrins, including cyclodextrins; polyols such asmannitol and sorbitol; chelating agents such as EDTA; and salt-formingcounter-ions such as sodium.

Examples of carriers that may be used in the formulations of the presentinvention include water, mixtures of water and water-miscible solvents,such as C₁- to C₇-alkanols, vegetable oils or mineral oils comprisingfrom 0.5 to 5% non-toxic water-soluble polymers, natural products, suchas gelatin, alginates, pectins, tragacanth, karaya gum, xanthan gum,carrageenin, agar and acacia, starch derivatives, such as starch acetateand hydroxypropyl starch, and also other synthetic products, such aspolyvinyl alcohol, polyvinylpyrrolidone, polyvinyl methyl ether,polyethylene oxide, preferably cross-linked polyacrylic acid, such asneutral Carbopol, or mixtures of those polymers. The concentration ofthe carrier is, typically, from 1 to 100000 times the concentration ofthe active ingredient.

In a particular embodiment, the carrier is a polymeric, mucoadhesivevehicle. Examples of mucoadhesive vehicles suitable for use in themethods or formulations of the invention include but are not limited toaqueous polymeric suspensions comprising one or more polymericsuspending agents including without limitation dextrans, polyethyleneglycol, polyvinylpyrolidone, polysaccharide gels, Gelrite®, cellulosicpolymers, and carboxy-containing polymer systems. In a particularembodiment, the polymeric suspending agent comprises a crosslinkedcarboxy-containing polymer (e.g., polycarbophil). In another particularembodiment, the polymeric suspending agent comprises polyethylene glycol(PEG). Examples of cross-linked carboxy-containing polymer systemssuitable for use in the topical stable ophthalmic cetirizineformulations of the invention include but are not limited to NoveonAA-1, Carbopol®, and/or DuraSite® (InSite Vision).

In particular embodiments, the cetirizine formulations of the inventioncomprise one or more excipients selected from among the following: atear substitute, a tonicity enhancer, a preservative, a solubilizer, aviscosity enhancing agent, a demulcent, an emulsifier, a wetting agent,a sequestering agent, and a filler. The amount and type of excipientadded is in accordance with the particular requirements of theformulation and is generally in the range of from about 0.0001% to 90%by weight.

Tear Substitutes

The term “tear substitute” refers to molecules or compositions whichlubricate, “wet,” approximate the consistency of endogenous tears, aidin natural tear build-up, or otherwise provide temporary relief of dryeye signs or symptoms and conditions upon ocular administration. Avariety of tear substitutes are known in the art and include, but arenot limited to: monomeric polyols, such as, glycerol, propylene glycol,and ethylene glycol; polymeric polyols such as polyethylene glycol;cellulose esters such hydroxypropylmethyl cellulose, carboxymethylcellulose sodium and hydroxy propylcellulose; dextrans such as dextran70; water soluble proteins such as gelatin; vinyl polymers, such aspolyvinyl alcohol, polyvinylpyrrolidone, and povidone; and carbomers,such as carbomer 934P, carbomer 941, carbomer 940 and carbomer 974P.Many such tear substitutes are commercially available, which include,but are not limited to cellulose esters such as Bion Tears®, Celluvisc®,Genteal®, OccuCoat®, Refresh®, Systane®, Systane Ultra®, Endura®,Liquigel®, Teargen II®, Tears Naturale®, Tears Natural II®, TearsNaturale Free®, and TheraTears®; and polyvinyl alcohols such as AkwaTears®, HypoTears®, Moisture Eyes®, Murine Lubricating®, and VisineTears®, Soothe®. Tear substitutes may also be comprised of paraffins,such as the commercially available Lacri-Lube@ ointments. Othercommercially available ointments that are used as tear substitutesinclude Lubrifresh PM®, Moisture Eyes PM® and Refresh PM®.

In one preferred embodiment of the invention, the tear substitutecomprises hydroxypropylmethyl cellulose (Hypromellose or HPMC).According to some embodiments, the concentration of HPMC ranges fromabout 0.1% to about 2% w/v, or any specific value within said range.According to some embodiments, the concentration of HPMC ranges fromabout 0.5% to about 1.5% w/v, or any specific value within said range.According to some embodiments, the concentration of HPMC ranges fromabout 0.1% to about 1% w/v, or any specific value within said range.According to some embodiments, the concentration of HPMC ranges fromabout 0.6% to about 1% w/v, or any specific value within said range. Ina preferred embodiments, the concentration of HPMC ranges from about0.1% to about 1.0% w/v, or any specific value within said range (i.e.,0.1-0.2%, 0.2-0.3%, 0.3-0.4%, 0.4-0.5%, 0.5-0.6%, 0.6-0.7%, 0.7-0.8%,0.8-0.9%, 0.9-1.0%; about 0.2%, about 0.21%, about 0.22%, about 0.23%,about 0.24%, about 0.25%, about 0.26%, about 0.27%, about 0.28%, about0.29%, about 0.30%, about 0.70%, about 0.71%, about 0.72%, about 0.73%,about 0.74%, about 0.75%, about 0.76%, about 0.77%, about 0.78%, about0.79%, about 0.80%, about 0.81%, about 0.82%, about 0.83%, about 0.84%,about 0.85%, about 0.86%, about 0.87%, about 0.88%, about 0.89%, orabout 0.90%).

For example, without limitation, a tear substitute which compriseshydroxypropyl methyl cellulose is GenTeal® lubricating eye drops.GenTeal® (CibaVision—Novartis) is a sterile lubricant eye dropcontaining hydroxypropylmethyl cellulose 3 mg/g and preserved withsodium perborate. Other examples of an HPMC-based tear are provided.

In another preferred embodiment, the tear substitute comprisescarboxymethyl cellulose sodium. For example, without limitation, thetear substitute which comprises carboxymethyl cellulose sodium isRefresh® Tears. Refresh® Tears is a lubricating formulation similar tonormal tears, containing a, mild non-sensitizing preservative,stabilised oxychloro complex (Purite®), that ultimately changes intocomponents of natural tears when used.

In another preferred embodiment, the tear substitute comprises PEGand/or propylene glycol. For example, without limitation, the tearsubstitute which comprises PEG and/or propylene glycol is Systane®.

In a preferred embodiment, the tear substitute, or one or morecomponents thereof, is an aqueous solution having a viscosity in a rangewhich optimizes efficacy of supporting the tear film while minimizingblurring, lid caking, etc. Preferably, the viscosity of the tearsubstitute, or one or more components thereof, ranges from 1-150centipoise (cpi), e.g., 5-150 cpi, 5-130 cpi, 30-130 cpi, 50-120 cpi,60-115 cpi (or any specific value within said ranges). In a particularembodiment, the viscosity of the tear substitute, or one or morecomponents thereof, is about 70-90 cpi, or any specific value withinsaid range (for example without limitation, 85 cpi).

Viscosity may be measured at a temperature of 20° C.+/−1° C. using aBrookfield Cone and Plate Viscometer Model VDV-III Ultra⁺ with a CP40 orequivalent Spindle with a shear rate of approximately 22.50+/−approximately 10 (1/sec), or a Brookfield Viscometer Model LVDV-E with aSC4-18 or equivalent Spindle with a shear rate of approximately 26+/−approximately 10 (1/sec). Alternatively, viscosity may be measured at25° C.+/−1° C. using a Brookfield Cone and Plate Viscometer ModelVDV-III Ultra⁺ with a CP40 or equivalent Spindle with a shear rate ofapproximately 22.50+/− approximately 10 (1/sec), or a BrookfieldViscometer Model LVDV-E with a SC4-18 or equivalent Spindle with a shearrate of approximately 26+/− approximately 10 (1/sec).

In some embodiments, the tear substitute, or one or more componentsthereof is buffered to a pH 5.0 to 9.0, preferably pH 5.5 to 7.5, morepreferably pH 6.0 to 7.0 (or any specific value within said ranges),with a suitable salt (e.g., phosphate salts). In some embodiments, thetear substitute further comprises one or more ingredients, includingwithout limitation, glycerol, propyleneglycerol, glycine, sodium borate,magnesium chloride, and zinc chloride.

Salts, Buffers, and Preservatives

The formulations of the present invention may also containpharmaceutically acceptable salts, buffering agents, or preservatives.Examples of such salts include those prepared from the following acids:hydrochloric, hydrobromic, sulfuric, nitric, phosphoric, maleic, acetic,salicylic, citric, boric, formic, malonic, succinic, and the like. Suchsalts can also be prepared as alkaline metal or alkaline earth salts,such as sodium, potassium or calcium salts. Examples of buffering agentsinclude phosphate, citrate, acetate, and 2-(N-morpholino)ethanesulfonicacid (MES).

For the adjustment of the pH, preferably to a physiological pH, buffersmay especially be useful. The pH of the present solutions should bemaintained within the range of 4.0 to 8.0, more preferably about 5.5 to7.5, more preferably about 6.0 to 7.0. Suitable buffers may be added,such as boric acid, sodium borate, potassium citrate, citric acid,sodium bicarbonate, TRIS, and various mixed phosphate buffers (includingcombinations of Na₂HPO₄, NaH₂PO₄ and KH₂PO₄) and mixtures thereof.Borate buffers are preferred. Generally, buffers will be used in amountsranging from about 0.05 to 2.5 percent by weight, and preferably, from0.1 to 1.5 percent.

In certain embodiments, the topical formulations additionally comprise apreservative. A preservative may typically be selected from a quaternaryammonium compound such as benzalkonium chloride, benzoxonium chloride orthe like. Benzalkonium chloride is better described as:N-benzyl-N—(C₈-C₁₈ alkyl)-N,N-dimethylammonium chloride. Furtherexamples of preservatives include antioxidants such as vitamin A,vitamin E, vitamin C, retinyl palmitate, and selenium; the amino acidscysteine and methionine; citric acid and sodium citrate; and syntheticpreservatives such as thimerosal, and alkyl parabens, including forexample, methyl paraben and propyl paraben. Other preservatives includeoctadecyldimethylbenzyl ammonium chloride, hexamethonium chloride,benzethonium chloride, phenol, catechol, resorcinol, cyclohexanol,3-pentanol, m-cresol, phenylmercuric nitrate, phenylmercuric acetate orphenylmercuric borate, sodium perborate, sodium chlorite, alcohols, suchas chlorobutanol, butyl or benzyl alcohol or phenyl ethanol, guanidinederivatives, such as chlorohexidine or polyhexamethylene biguanide,sodium perborate, Polyquad®, Germal®II, sorbic acid and stabilizedoxychloro complexes (e.g., Purite®). Preferred preservatives arequaternary ammonium compounds, in particular benzalkonium chloride orits derivative such as Polyquad (see U.S. Pat. No. 4,407,791),alkyl-mercury salts, parabens and stabilized oxychloro complexes (e.g.,Purite®). Where appropriate, a sufficient amount of preservative isadded to the ophthalmic composition to ensure protection againstsecondary contaminations during use caused by bacteria and fungi.

In particular embodiments, the cetirizine formulations of the inventioncomprise a preservative selected from among the following: benzalkoniumchloride, 0.001% to 0.05%; benzethonium chloride, up to 0.02%; sorbicacid, 0.01% to 0.5%; polyhexamethylene biguanide, 0.1 ppm to 300 ppm;polyquaternium-1 (Omamer M)—0.1 ppm to 200 ppm; hypochlorite,perchlorite or chlorite compounds, 500 ppm or less, preferably between10 and 200 ppm); stabilized hydrogen peroxide solutions, a hydrogenperoxide source resulting in a weight % hydrogen peroxide of 0.0001 to0.1% along with a suitable stabilizer; alkyl esters of p-hydroxybenzoicacid and mixtures thereof, preferably methyl paraben and propyl paraben,at 0.01% to 0.5%; chlorhexidine, 0.005% to 0.01%; chlorobutanol, up to0.5%; and stabilized oxychloro complex (Purite®) 0.001% to 0.5%, orsepazonium 0.0001% to 0.1%.

In another embodiment, the topical formulations of this invention do notinclude a preservative. Such formulations would be useful for patients,who wear contact lenses, or those who use several topical ophthalmicdrops and/or those with an already compromised ocular surface (e.g. dryeye) wherein limiting exposure to a preservative may be more desirable.

Viscosity Enhancing Agents and Demulcents

In certain embodiments, viscosity enhancing agents may be added to thecetirizine formulations of the invention. Examples of such agentsinclude polysaccharides, such as hyaluronic acid and its salts,chondroitin sulfate and its salts, dextrans, various polymers of thecellulose family, vinyl polymers, and acrylic acid polymers.

In certain embodiments, the cetirizine formulations of the inventioncomprise ophthalmic demulcents and/or viscosity enhancing polymersselected from one or more of the following: cellulose derivatives suchas carboxymethycellulose (0.01 to 5%) hydroxyethylcellulose (0.01% to5%), hydroxypropyl methylcellulose or hypromellose (0.01% to 5%), andmethylcelluose (0.02% to 5%); dextran 40/70 (0.01% to 1%); gelatin(0.01% to 0.1%); polyols such as glycerin (0.01% to 5%), polyethyleneglycol 300 (0.02% to 5%), polyethylene glycol 400 (0.02% to 5%),polysorbate 80 (0.02% to 3%), propylene glycol (0.02% to 3%), polyvinylalcohol (0.02% to 5%), and povidone (0.02% to 3%); hyaluronic acid(0.01% to 2%); and chondroitin sulfate (0.01% to 2%).

Viscosity of the stable ophthalmic cetirizine formulations of theinvention may be measured according to standard methods known in theart, such as use of a viscometer or rheometer. One of ordinary skill inthe art will recognize that factors such as temperature and shear ratemay effect viscosity measurement. In a particular embodiment, viscosityof the is measured at 20° C.+/−1° C. using a Brookfield Cone and PlateViscometer Model VDV-III Ultra+ with a CP40 or equivalent Spindle with ashear rate of approximately 22.50+/− approximately 10 (1/sec), or aBrookfield Viscometer Model LVDV-E with a SC4-18 or equivalent Spindlewith a shear rate of approximately 26+/− approximately 10 (1/sec). Inanother embodiment, viscosity of the ophthalmic formulations of theinvention is measured at 25° C.+/−1° C. using a Brookfield Cone andPlate Viscometer Model VDV-III Ultra+ with a CP40 or equivalent Spindlewith a shear rate of approximately 22.50+/− approximately 10 (1/sec), ora Brookfield Viscometer Model LVDV-E with a SC4-18 or equivalent Spindlewith a shear rate of approximately 26+/− approximately 10 (1/sec).

Tonicity Enhancers

Tonicity is adjusted if needed typically by tonicity enhancing agents.Such agents may, for example be of ionic and/or non-ionic type. Examplesof ionic tonicity enhancers are alkali metal or earth metal halides,such as, for example, CaCl₂, KBr, KCl, LiCl, NaI, NaBr or NaCl, Na₂SO₄or boric acid. Non-ionic tonicity enhancing agents are, for example,urea, glycerol, sorbitol, mannitol, propylene glycol, or dextrose. Theaqueous solutions of the present invention are typically adjusted withtonicity agents to approximate the osmotic pressure of normal lachrymalfluids which is equivalent to a 0.9% solution of sodium chloride or a2.5% solution of glycerol. An osmolality of about 225 to 400 mOsm/kg ispreferred, more preferably 280 to 320 mOsm.

Solubilizing Agents

The topical formulation may additionally require the presence of asolubilizer, in particular if one or more of the ingredients tend toform a suspension or an emulsion. Suitable solubilizers include, forexample, tyloxapol, fatty acid glycerol polyethylene glycol esters,fatty acid polyethylene glycol esters, polyethylene glycols, glycerolethers, polysorbate 20, polysorbate 80 or mixtures of those compounds.In a preferred embodiment, the solubilizer is a reaction product ofcastor oil and ethylene oxide, for example the commercial productsCremophor EL® or Cremophor RH40®. Reaction products of castor oil andethylene oxide have proved to be particularly good solubilizers that aretolerated extremely well by the eye. In another embodiment, thesolubilizer is tyloxapol or a cyclodextrin. The concentration useddepends especially on the concentration of the active ingredient. Theamount added is typically sufficient to solubilize the activeingredient. For example, the concentration of the solubilizer is from0.1 to 5000 times the concentration of the active ingredient.Preferably, the solubilizer is not a cyclodextrin compound (for examplealpha-, beta- or gamma-cyclodextrin, e.g. alkylated, hydroxyalkylated,carboxyalkylated or alkyloxycarbonyl-alkylated derivatives, or mono- ordiglycosyl-alpha-, beta- or gamma-cyclodextrin, mono- ordimaltosyl-alpha-, beta- or gamma-cyclodextrin or panosyl-cyclodextrin).

Examples of Formulations

In a preferred embodiment, the cetirizine formulation comprisescetirizine at 0.05% to 0.25% (w/v), glycerin at 0.1% to 5% (v/v) (e.g.,0.1% to 3% (v/v) or any specific value within said range), and water. Inparticular embodiments the cetirizine formulation of the invention doesnot contain a cyclodextrin or other solubilizing compound. Optionally,the formulation also comprises a preservative such as benzalkoniumchloride at 0.005% to 0.02% (w/v) or its derivative (e.g., Polyquad®),or a stabilized oxychloro complex such as Purite®. In a particularembodiment, the cetirizine formulation comprises cetirizine at 0.1%(w/v), glycerin at 1.2% to 3% (v/v), and water. In another particularembodiment, the cetirizine 0.1% (w/v), glycerin 1.2% to 3% (v/v), andwater formulation also comprises benzalkonium chloride at 0.01% (w/v) ora stabilized, oxychloro complex (e.g., Purite®). The pH of theformulation is between 5.0 and 7.5 for example, the pH of theformulation is 5, 5.5, 6.0, 6.5, 7.0, 7.2, 7.4 or 7.5.

In a preferred embodiment, the cetirizine formulation comprisescetirizine at 0.08% to 0.12% (w/v), glycerin at 0.1% to 5% (v/v) (e.g.,0.1% to 3% (v/v) or any specific value within said range), and water. Inparticular embodiments the cetirizine formulation of the invention doesnot contain a cyclodextrin or other solubilizing compound. Optionally,the formulation also comprises a preservative such as benzalkoniumchloride at 0.005% to 0.02% (w/v) or its derivative (e.g., Polyquad®),or a stabilized oxychloro complex such as Purite®. In a particularembodiment, the cetirizine formulation comprises cetirizine at 0.1%(w/v), glycerin at 1.2% to 3% (v/v), and water. In another particularembodiment, the cetirizine 0.1% (w/v), glycerin 1.2% to 3% (v/v), andwater formulation also comprises benzalkonium chloride at 0.01% (w/v) ora stabilized, oxychloro complex (e.g., Purite®). The pH of theformulation is between 5.0 and 7.5 for example, the pH of theformulation is 5, 5.5, 6.0, 6.5, 7.0, 7.2, 7.4 or 7.5.

In a specific embodiment, the cetirizine formulation comprisescetirizine at 0.1% (w/v), glycerin at 2.125% (v/v), benzalknoiumchloride at 0.01% (w/v), q.s. with water. In one embodiment, thecetirizine formulation comprises cetirizine as the only activeingredient at 0.05% to 0.25% (w/v) and optionally one or more tearsubstitutes or a mucoadhesive, polymeric compound (e.g., Durasite®).Preferably, the cetirizine formulations do not contain a cyclodextrin orother solubilizing compound.

Where the formulation comprises one or more tear substitutes, the tearsubstitute preferably contains hydroxypropylmethyl cellulose orcarboxymethyl cellulose or both. In some embodiments, thehydroxypropylmethyl cellulose or carboxymethyl cellulose is present at aconcentration of 0.5% to 1% (w/v) (or any specific value within saidrange) and the resulting viscosity of the solution is 60-80 cpi. In aparticular embodiment, the hydroxypropylmethyl cellulose orcarboxymethyl cellulose is present at a concentration of 0.7% to 0.9%.In another particular embodiment, the hydroxypropylmethyl cellulose orcarboxymethyl cellulose is present at a concentration of 0.1% to 0.7%and the resulting viscosity of the solution is 10-30 cpi. Optionally,the formulation also comprises a preservative, preferably benzalkoniumchloride at a concentration of from 0.005% to 0.02% (w/v) (or anyspecific value within said range) or its derivative (e.g., Polyquad®),or a stabilized oxychloro complex (e.g., Purite®), or sodium perborate,or sorbate or sepazonium. The pH of the formulation is between 5.0 and7.5. For example, the pH of the formulation is 5, 5.5, 6.0, 6.5, 7.0,7.2, 7.4 or 7.5.

In another preferred embodiment, the cetirizine formulation comprisescetirizine at 0.05% to 0.25% (w/v), naphazoline at 0.01% to 0.2% (w/v),glycerin at 0.1% to 5% (v/v) (e.g., 0.1% to 3% (v/v) or any specificvalue within said range), and water. Preferably, thecetirizine/naphazoline formulation does not contain a cyclodextrin orother solubilizing compound. Optionally, the formulation also comprisesbenzalkonium chloride at 0.005% to 0.02% (w/v) or its derivative (e.g.,Polyquad®), or a stabilized oxychloro complex such as Purite®. In aparticular embodiment, the cetirizine formulation comprises cetirizineat 0.1% (w/v), naphazoline at 0.09% (w/v), glycerin at 1.2% to 3% (v/v),and water. In another particular embodiment, the cetirizine 0.1% (w/v),naphazoline 0.09% (w/v), glycerin at 1.2% to 3% (v/v), and waterformulation also comprises benzalkonium chloride at 0.01% (w/v) or astabilized oxychloro complex such as Purite®. The pH of the formulationis between 5.0 and 7.5. For example, the pH of the formulation is 5,5.5, 6.0, 6.5, 7.0, 7.2, 7.4 or 7.5.

In yet another preferred embodiment, the cetirizine formulationcomprises cetirizine at 0.05% to 0.25% (w/v), naphazoline at 0.01% to0.2% (w/v), and one or more tear substitutes or a mucoadhesive polymericcompound (e.g., Durasite®). In particular embodiments the cetirizineformulation does not contain a cyclodextrin or other solubilizingcompound. Where the formulation comprises one or more tear substitutes,the tear substitute preferably contains hydroxypropylmethyl cellulose orcarboxymethyl cellulose, or both. In some embodiments, thehydroxypropylmethyl cellulose or carboxymethyl cellulose is present at aconcentration of 0.5% to 1% (w/v) (or any specific value within saidrange) and the resulting viscosity of the solution is 60-80 cpi. In aparticular embodiment, the hydroxypropylmethyl cellulose orcarboxymethyl cellulose is present at a concentration of 0.7% to 0.9%.Optionally, the formulation also comprises a preservative, preferablybenzalkonium chloride at a concentration of from 0.005% to 0.02% (w/v)(or any specific value within said range) or stabilised oxychlorocomplex (Purite®). The pH of the formulation is between 5.0 and 7.5. Forexample, the pH of the formulation is 5, 5.5, 6.0, 6.5, 7.0, 7.2, 7.4 or7.5.

In yet another preferred embodiment, the cetirizine formulationcomprises cetirizine at 0.05% to 0.25% (w/v), oxymetazoline at 0.01% to0.1% (w/v), glycerin at 0.1% to 5% (v/v) (e.g., 0.1% to 3% (v/v) or anyspecific value within said range), and water. Preferably, thecetirizine/oxymetazoline formulation does not contain a cyclodextrin orother solubilizing compound. Optionally, the formulation also comprisesbenzalkonium chloride at 0.005% to 0.02% (w/v) or its derivative (e.g.,Polyquad®), or a stabilized, oxychloro complex (e.g., Purite®). In aparticular embodiment, the cetirizine formulation comprises cetirizineat 0.1% (w/v), oxymetazoline at 0.05% (w/v), glycerin at 1.2% to 3%(v/v), and water. In another particular embodiment, the cetirizine 0.1%(w/v), oxymetazoline 0.05% (w/v), glycerin 1.2% to 3% (v/v), and waterformulation also comprises benzalkonium chloride at 0.01% (w/v) or astabilized, oxychloro complex (e.g., Purite®). In certain embodiments,the pH of the formulation is between 5.0 and 7.5. For example, the pH ofthe formulation is 5, 5.5, 6.0, 6.5, 7.0, 7.2, 7.4 or 7.5.

In still another preferred embodiment, the cetirizine formulationcomprises cetirizine at 0.05% to 0.25% (w/v), oxymetazoline at 0.01% to0.1% (w/v), and one or more tear substitutes or a mucoadhesive,polymeric compound (e.g., Durasite®). Preferably, thecetirizine/oxymetazoline formulation does not contain a cyclodextrin orother solubilizing compound. Where the formulation comprises one or moretear substitutes, the tear substitute preferably containshydroxypropylmethyl cellulose or carboxymethyl cellulose or both. Insome embodiments, the hydroxypropylmethyl cellulose or carboxymethylcellulose is present at a concentration of 0.5% to 1% (w/v) (or anyspecific value within said range) and the resulting viscosity of thesolution is 60-80 cpi. In a particular embodiment, thehydroxypropylmethyl cellulose or carboxymethyl cellulose is present at aconcentration of 0.7% to 0.9%. Optionally, the formulation alsocomprises a preservative, preferably benzalkonium chloride at aconcentration of from 0.005% to 0.02% (w/v) (or any specific valuewithin said range) or a stabilized oxychloro complex (Purite®). The pHof the formulation is between 5.0 and 7.5. For example, the pH of theformulation is 5, 5.5, 6.0, 6.5, 7.0, 7.2, 7.4 or 7.5.

In still another preferred embodiment, the cetirizine formulationcomprises cetirizine at 0.05% to 0.5% (w/v), fluticasone at 0.001% to1.0% (w/v), glycerin at 0.1% to 5% (v/v) (e.g., 0.1% to 3% (v/v) or anyspecific value within said range), and water. Preferably, thecetirizine/fluticasone formulation does not contain a cyclodextrin orother solubilizing compound. Optionally, the formulation also comprisesbenzalkonium chloride at 0.005% to 0.02% (w/v) or its derivative (e.g.,Polyquad®), or a stabilized, oxychloro complex (e.g., Purite®). In aparticular embodiment, the cetirizine formulation comprises cetirizineat 0.1% (w/v), fluticasone at 0.005%, glycerin at 1.2% to 3% (v/v), andwater. In another particular embodiment, the cetirizine formulationcomprises cetirizine at 0.25% (w/v), fluticasone at 0.01% (w/v),glycerin at 1.2% to 3% (v/v), and water. Optionally, thecetirizine/fluticasone formulations also comprises benzalkonium chlorideat 0.01% (w/v) or a stabilized, oxychloro complex (e.g., Purite®). ThepH of the formulation is between 5.0 and 7.5. For example, the pH of theformulation is 5, 5.5, 6.0, 6.5, 7.0, 7.2, 7.4 or 7.5.

In yet another preferred embodiment, the cetirizine formulationcomprises cetirizine at 0.05% to 0.5% (w/v), fluticasone at 0.001% to1.0% (w/v), preferably fluticasone 0.005%, and one or more tearsubstitutes or a mucoadhesive, polymeric compound (e.g., Durasite®).Preferably, the cetirizine/fluticasone formulation does not contain acyclodextrin or other solubilizing compound. Where the formulationcomprises one or more tear substitutes, the tear substitute preferablycontains hydroxypropylmethyl cellulose or carboxymethyl cellulose orboth. In some embodiments, the hydroxypropylmethyl cellulose orcarboxymethyl cellulose is present at a concentration of 0.5% to 1%(w/v) (or any specific value within said range) and the resultingviscosity of the solution is 60-80 cpi. In a particular embodiment, thehydroxypropylmethyl cellulose or carboxymethyl cellulose is present at aconcentration of 0.7% to 0.9%. Optionally, the formulation alsocomprises a preservative, preferably benzalkonium chloride at aconcentration of from 0.005% to 0.02% (w/v) (or any specific valuewithin said range) or stabilized oxychloro complex (Purite®). The pH ofthe formulation is between 5.0 and 7.5. For example, the pH of theformulation is 5, 5.5, 6.0, 6.5, 7.0, 7.2, 7.4 or 7.5.

In still another preferred embodiment, the cetirizine formulationcomprises 0.1% cetirizine, 0.005% fluticasone, 1% Polyethylene Glycol400, NF, 0.2% Dibasic Sodium Phosphate, Anhydrous, USP, 0.25%Hypromellose, USP, 0.1% Polysorbate 80, NF, 1.8% Glycerin, USP, 0.025%Edetate Disodium, USP, and 0.01% Benzalkonium Chloride, NF (pH 7.0).

In yet another preferred embodiment, the cetirizine formulationcomprises 0.25% cetirizine, 0.01% fluticasone, 1% Polyethylene Glycol400, NF, 0.2% Dibasic Sodium Phosphate, Anhydrous, USP, 0.25%Hypromellose, USP; 0.1% Polysorbate 80, NF, 1.2% Glycerin, USP, 0.025%Edetate Disodium, USP, and 0.01% Benzalkonium Chloride, NF (pH 7.0).

The formulations of the present invention provide for the chemicalstability of the formulated cetirizine and other optional active agents(e.g., napahzoline, oxymetazoline, fluticasone, or combinations thereof)of the formulation, without the use of a cyclodextrin or othersolubilizing compound. “Stability” and “stable” in this context refersto the resistance of the cetirizine and other optional active agents tochemical degradation under given manufacturing, preparation,transportation and storage conditions. The “stable” formulations of theinvention also preferably retain at least 90%, 95%, 98%, 99%, or 99.5%of a starting or reference amount under given manufacturing,preparation, transportation, and/or storage conditions. The amount ofcetirizine and other optional active agents can be determined using anyart-recognized method, for example, as UV-Vis spectrophotometry and highpressure liquid chromatography (HPLC).

In certain embodiments, the cetirizine formulations are stable attemperatures ranging from about 20 to 30° C. for at least 1 week, atleast 2 weeks, at least 3 weeks, at least 4 weeks, at least 5 weeks, atleast 6 weeks, or at least 7 weeks. In other embodiments, the cetirizineformulations are stable at temperatures ranging from about 20 to 30° C.for at least 1 month, at least 2 months, at least 3 months, at least 4months, at least 5 months, at least 6 months, at least 7 months, atleast 8 months, at least 9 months, at least 10 months, at least 11months, or at least 12 months. In one embodiment, the formulation isstable for at least 3 months at 20-25° C.

In other embodiments, the cetirizine formulations are stable attemperatures ranging from about 2 to 8° C. for at least 1 month, atleast 2 months, at least 4 months, at least 6 months, at least 8 months,at least 10 months, at least 12 months, at least 14 months, at least 16months, at least 18 months, at least 20 months, at least 22 months, orat least 24 months. In one embodiment, the formulation is stable for atleast 2 months at 2 to 8° C.

In other embodiments, the cetirizine formulations are stable attemperatures of about −20° C. for at least 1 month, at least 2 months,at least 4 months, at least 6 months, at least 8 months, at least 10months, at least 12 months, at least 14 months, at least 16 months, atleast 18 months, at least 20 months, at least 22 months, or at least 24months. In one embodiment, the formulation is stable for at least 6-12months at −20° C.

In a particular embodiment, a cetirizine formulation of the invention isstable at temperatures of about 20-30° C. at concentrations up to 0.10%for at least 3 months. In another embodiment, the formulation is stableat temperatures from about 2-8° C. at concentrations up to 0.10% for atleast 6 months.

Methods of Use

The cetirizine formulations of the invention are useful for thetreatment and prevention of the signs and symptoms of both the acutephase and late phase inflammatory reactions, i.e. allergic disorders.The allergic disorder is against an airborne allergen. In particularembodiments the allergic disorder is a nasal allergy, an ocular allergyor both. More specifically, the cetirizine formulations of the inventionare useful for the treatment and prevention of the signs and symptoms ofboth the acute phase and late phase inflammatory reactions (i.e.,chronic, persistent or refractory) of allergic conjunctivitis, such asocular itching, redness, chemosis, tearing, and eyelid swelling, as wellas associated nasal symptoms with rhinitis and/or rhinoconjunctivitis,including nasal itching, congestion, rhinorrhea, sneezing, itchy palate,itchy ear. The formulations of the invention are also useful for thetreatment and prevention of the signs and symptoms of allergicrhinoconjunctivitis, which may have both ocular and/or nasal signs andsymptoms

The invention provides methods of treating or preventing allergicconjunctivitis, rhinitis and/or allergic rhinoconjunctivitis in asubject in need thereof comprising topically administering to the eyesurface of the subject an ophthalmic formulation comprising an effectiveamount of cetirizine. In certain embodiments, the administration ofcetirizine to the eye of a subject in need of treatment or prevention ofallergic conjunctivitis and/or rhinitis and/or rhinoconjunctivitis isalso effective to mitigate or reduce one or more nasal symptoms. Topicaladministration of the ophthalmic formulations directly to the eye of asubject will significantly reduce nasal signs and symptoms via drainagefrom the ocular surface into the nasal cavity through the nasolacrimalduct (See e.g., Abelson et al., Clin. Ther. 25(3), 931-947 (2003);Spangler et al., Clin. Ther. 25(8), 2245-2267 (2003); and Crampton etal., Clin Ther. November; 24(11):1800-8 (2002). Surprisingly,significantly less active agent is required to treat the nasal symptomswhen instilled through the eye of a subject as compared toadministration through the nose of the subject. For example, each sprayof Flonase® (commercially available nasal spray comprising fluticasone)delivers 0.5 milligrams of fluticasone to the nasal cavity to treatallergic rhinitis and allergic rhinoconjunctivitis. In contrast, onedrop of a 0.005% fluticasone ophthalmic formulation (i.e., 2.5micrograms in a 50 microliter drop) has been shown to significantlyreduce nasal symptoms associated with ocular allergy when topicallyadministered directly to the eye (see Example 2 herein) when dosed oncedaily (QD). As such, the methods of the present invention may be moreeffective than the currently available treatment options for nasalsymptoms of allergic conjunctivitis and/or rhinitis and/or allergicrhinoconjunctivitis.

The subject is preferably a human, but may be another mammal, forexample a dog, a cat, a horse, a rabbit, a mouse, a rat, or a non-humanprimate.

The formulations of the present invention contain an amount ofcetirizine, and optionally one or more additional active ingredients(for example without limitation a vasoconstrictor such as naphazoline oroxymetazoline, or a steroid such as fluticasone), that is effective forthe intended use (i.e., to mitigate the signs and symptoms of allergicconjunctivitis and/or rhinitis and/or rhinoconjunctivitis). In certainembodiments, surprisingly a concentration was identified with once a dayadministration of the formulations of the present invention to beeffective to mitigate the symptoms of allergic conjunctivitis, rhinitis,and/or rhinoconjunctivitis, yet be low enough in concentration not toimpact IOP significantly. However, particular dosages are also selectedbased on a number of factors including the age, sex, species andcondition of the subject. Effective amounts can also be extrapolatedfrom dose-response curves derived from in vitro test systems or fromanimal models. The term “effective amount” means an amount of cetirizinethat is sufficient to eliminate or reduce a symptom of allergicconjunctivitis, rhinitis and/or rhinoconjunctivitis. In certainembodiments, the effective amount is the amount sufficient for thetreatment or prevention of allergic conjunctivitis, rhinitis and/orrhinoconjunctivitis. “Treatment” in this context refers to reducing orameliorating at least one symptom of allergic conjunctivitis and/orrhinitis and/or rhinoconjunctivitis. “Prevention” in this context refersto a reduction in the frequency of, or a delay in the onset of, symptomsassociated with allergic conjunctivitis, rhinitis and/orrhinoconjunctivitis, relative to a subject who does not receive thecomposition. The effective amount of cetirizine and other active agentsin the formulation will depend on absorption, inactivation, andexcretion rates of the drug as well as the delivery rate of the compoundfrom the formulation. Particular dosages may also vary with the severityof the condition to be alleviated. It is to be further understood thatfor any particular subject, specific dosage regimens should be adjustedover time according to the individual need and the professional judgmentof the person administering or supervising the administration of thecompositions. Typically, a dosing regiment will be determined usingtechniques known to one skilled in the art.

Examples of dosing regimens that can be used in the methods of theinvention include, but are not limited to, once daily, twice daily,three times, and four times daily, or as-needed (PRN) for intermittentuse. In certain embodiments, the method comprises administering acetirizine formulation of the invention to the eye of the subject once aday. In some embodiments, the administration is 2 to 4 times a day.

In certain embodiments, the cetirizine formulations including thecombination of cetirizine/fluticasone is useful when applied to the eyeto treat nasal symptoms of patients with blocked nasal passages.

In certain embodiments, once a day administration (q.d.) is effective tomitigate the symptoms of ocular and/or nasal allergy. However,particular dosages may also be selected based on a number of factorsincluding the age, sex, species and condition of the subject. Effectiveamounts can also be extrapolated from dose-response curves derived fromin vitro test systems or from animal models.

The combined use of several active agents formulated into thecompositions of the present invention may reduce the required dosage forany individual component because the onset and duration of effect of thedifferent components may be complimentary. In such combined therapy, thedifferent active agents may be delivered together or separately, andsimultaneously or at different times within the day.

In a particular embodiment, a formulation comprising cetirizine as theonly active agent in the formulation is administered to the eye of asubject in need of treatment or prevention of an allergicconjunctivitis, rhinitis and/or rhinoconjunctivitis once daily (q.d.).In certain embodiments, the combination formulation is administered twoto four times a day.

In another particular embodiment, cetirizine is formulated with one ormore of naphazoline, oxymetazoline or fluticasone, and administered tothe eye of a subject in need of treatment or prevention of allergicconjunctivitis and/or rhinoconjunctivitis once daily (q.d.). In certainembodiments, the combination formulation is administered two to fourtimes a day.

In a preferred embodiment, cetirizine is formulated with fluticasone andadministered to the eyed of a subject in need of treatment or preventionof allergic conjunctivitis, rhinitis and/or rhinoconjunctivitis.Surprisingly the combination formulations of cetirizine and fluticasoneas described herein were more effective at relieving itching than couldbe predicted from the efficacy of each component individually. Even moresurprising was the finding that lower doses of cetirizine andfluticasone were more effective at relieving ocular itching andassociated nasal symptoms of allergic conjunctivitis than higher dosesof the individual components alone, or in combination. For example, asdescribed in the Examples, a 0.1% cetirizine/0.005% fluticasoneformulation (low dose) was more efficacious than 0.25% cetirizine/0.01%fluticasone formulation (high dose). Similarly, in a clinical studydescribed herein, the efficacy of 0.005% fluticasone was moreefficacious than the higher dose 0.01% fluticasone.

Packaging

The formulations of the present invention may be packaged as either asingle dose product or a multi-dose product. The single dose product issterile prior to opening of the package and all of the composition inthe package is intended to be consumed in a single application to one orboth eyes of a patient. The use of an antimicrobial preservative tomaintain the sterility of the composition after the package is opened isgenerally unnecessary.

Multi-dose products are also sterile prior to opening of the package.However, because the container for the composition may be opened manytimes before all of the composition in the container is consumed, themulti-dose products must have sufficient antimicrobial activity toensure that the compositions will not become contaminated by microbes asa result of the repeated opening and handling of the container. Thelevel of antimicrobial activity required for this purpose is well knownto those skilled in the art, and is specified in official publications,such as the United States Pharmacopoeia (“USP”) and correspondingpublications in other countries. Detailed descriptions of thespecifications for preservation of ophthalmic pharmaceutical productsagainst microbial contamination and the procedures for evaluating thepreservative efficacy of specific formulations are provided in thosepublications. In the United States, preservative efficacy standards aregenerally referred to as the “USP PET” requirements. (The acronym “PET”stands for “preservative efficacy testing.”)

The use of a single dose packaging arrangement eliminates the need foran antimicrobial preservative in the compositions, which is asignificant advantage from a medical perspective in some cases, becauseconventional antimicrobial agents utilized to preserve ophthalmiccompositions (e.g., benzalkonium chloride) may cause ocular irritation,particularly in patients suffering from dry eye conditions, having acompromised ocular surface, using multiple preserved drops per day, orhave pre-existing ocular irritation. However, the single dose packagingarrangements currently available, such as small volume plastic vialsprepared by means of a process known as “form, fill and seal”, haveseveral disadvantages for manufacturers and consumers. The principaldisadvantages of the single dose packaging systems are the much largerquantities of packaging materials required, which is both wasteful andcostly, and the inconvenience for the consumer. Also, there is a riskthat consumers will not discard the single dose containers followingapplication of one or two drops to the eyes, as they are instructed todo, but instead will save the opened container and any compositionremaining therein for later use. This improper use of single doseproducts creates a risk of microbial contamination of the single doseproduct and an associated risk of ocular infection if a contaminatedcomposition is applied to the eyes.

While the formulations of this invention are preferably formulated as“ready for use” aqueous solutions, alternative formulations arecontemplated within the scope of this invention. Thus, for example, theactive ingredients, surfactants, salts, chelating agents, or othercomponents of the ophthalmic solution, or mixtures thereof, can belyophilized or otherwise provided as a dried powder or tablet ready fordissolution (e.g., in deionized, or distilled) water.

Kits

The present invention provides a pharmaceutical pack or kit comprisingone or more containers filled with a liquid or lyophilized cetirizineformulation of the invention (i.e., a formulation comprising cetirizinealone or in combination with an additional active agent as describedherein). In one embodiment, the formulation is an aqueous formulation ofcetirizine. In one embodiment, the formulation is lyophilized. Inpreferred embodiments the liquid or lyophilized formulation is sterile.In one embodiment, the kit comprises a liquid or lyophilized formulationof the invention, in one or more containers, and one or more otherprophylactic or therapeutic agents (e.g., cetirizine in combination withan additional active agent such as fluticasone, oxymetazoline ornaphazoline) useful for the treatment of allergic conjunctivitis and/orallergic rhinoconjunctivitis. The one or more other prophylactic ortherapeutic agents may be in the same container as the cetirizine or inone or more other containers. Preferably, the cetirizine is formulatedat a concentration of from about 0.05% (w/v) to about 1.0% (w/v) and issuitable for topical ocular administration. In certain embodiments,cetirizine is formulated with additional active agents such asfluticasone, oxymetazoline or naphazoline, as described herein. Incertain embodiments, the kit contains the cetirizine in unit dosageform.

In certain embodiments, the kit further comprises instructions for usein the treatment of allergic conjunctivitis and/or allergicrhinoconjunctivitis (e.g., using the cetirizine formulations of theinvention alone or in combination with another prophylactic ortherapeutic agent), as well as side effects and dosage information forone or more routes of administration. Optionally associated with suchcontainer(s) is a notice in the form prescribed by a governmental agencyregulating the manufacture, use or sale of pharmaceuticals or biologicalproducts, which notice reflects approval by the agency of manufacture,use or sale for human administration. While the instructional materialstypically comprise written or printed materials they are not limited tosuch. Any medium capable of storing such instructions and communicatingthem to an end user is contemplated by this invention. Such mediainclude, but are not limited to electronic storage media (e.g., magneticdiscs, tapes, cartridges, chips), optical media (e.g. CD ROM), and thelike. Such media may include addresses to internet sites that providesuch instructional materials.

In another embodiment, this invention provides kits for the packagingand/or storage and/or use of the formulations described herein, as wellas kits for the practice of the methods described herein. The kits canbe designed to facilitate one or more aspects of shipping, use, andstorage.

All publications and patents mentioned herein are hereby incorporated byreference in their entirety as if each individual publication or patentwas specifically and individually indicated to be incorporated byreference.

EXAMPLES

The invention is further defined by reference to the following examples,which are not meant to limit the scope of the present invention. It willbe apparent to those skilled in the art that many modifications, both tothe materials and methods, may be practiced without departing from thepurpose and interest of the invention.

Example 1 Cetirizine (0.1%) Prevents Ocular Itching Associated withAllergic Conjunctivitis

A placebo controlled, double-blind study was conducted to evaluate theefficacy of cetirizine 0.1% (N=15) compared to vehicle (N=16). Subjectsunderwent 2 screening visits (an allergen titration and confirmation)followed by a drug evaluation visit. At the drug evaluation visit, onedrop of masked study medication was instilled in each eye and comfortassessments were taken. Sixteen hours later the subjects were challengedwith allergen and allergic assessments were taken. The results arepresented in Tables 1 and 2 and in FIGS. 1-2. The ocular itching scoreranges from 0, no itching, to 4, severe itching. The comfort scoreranges from 0, very comfortable, to 10, very uncomfortable (Note: Themost uncomfortable commercially available allergy drop=4). The resultsdemonstrate that a single drop of cetirizine (0.1%) ophthalmic solution(q.d.) was effective to prevent ocular itching associated with allergicconjunctivitis when administered 16 hours prior to conjunctival allergenchallenge (CAC), but had little effect on reducing conjunctival redness(FIGS. 1A and 1B). Differences between cetirizine and vehicle groupswere both clinically (≧1 unit difference) and statistically significant(P<0.05). In addition, as shown in Table 2, and FIG. 2, the cetirizineformulation was comfortable (i.e., well-tolerated) by the subjects.

TABLE 1 Mean Ocular Itching Scores (0-4 scale) following CAC 16 hrsafter dosing Mean Cetirizine Difference Sta- Time- 0.1% HCl Vehicle(cetirizine − p- tistic point (N = 15) (N = 16) vehicle) value MeanPre-CAC 0.00 (0.00) 0.00 (0.00) 0.00 1.0000 (SD) 3 min 1.67 (1.12) 2.36(0.58) −0.69 0.0191 5 min 1.52 (1.12) 2.56 (0.60) −1.04 0.0051 7 min1.45 (1.02) 2.47 (0.72) −1.02 0.0031

TABLE 2 Mean Drop Comfort Scores (0-10 scale) Mean Cetirizine DifferenceSta- Time- 0.1% HCl Vehicle (cetirizine − p- tistic point (N = 15) (N =16) vehicle) value Mean Upon 0.47 (0.68) 0.72 (1.49) −0.25 0.3908 (SD)Instillation 1 min 0.37 (0.49) 0.84 (1.80) −0.47 0.1572 2 min 0.47(0.63) 0.81 (1.53) −0.34 0.2467 5 min 0.20 (0.41) 0.13 (0.34) 0.070.5981 10 min  0.27 (0.46) 0.31 (0.70) −0.04 0.7864

Example 2 Fluticasone Prevents Ocular and Nasal Symptoms Associated withAllergic Conjunctivitis, Rhinitis and Rhinoconjunctivitis

A placebo controlled, double-blind study was conducted to evaluate theefficacy of Fluticasone 0.001% (N=16), Fluticasone 0.005% (N=16),Fluticasone 0.01% (N=15) compared to vehicle alone (N=15). Subjectsunderwent 2 screening visits (allergen titration and confirmation)followed by 2 drug evaluation visits, as indicated in the study designshown in FIGS. 3A and 3B. At the drug evaluation visits, one drop ofmasked study medication was instilled in each eye and ocular allergicassessments were taken. Eight hours later the subjects were challengedwith allergen and primary and secondary ocular and nasal endpoints wereassessed, as well as safety of the formulations. The results arepresented in FIGS. 4-23.

Primary Ocular Endpoints

Ocular itching, conjunctival redness, lid swelling, and nasal congestionwere assessed in each subject during visit 4B.

Ocular itching was subjectively assessed on a scale of 0 (no itching) to4 (severe itching). As shown in FIG. 4, Fluticasone 0.001%, 0.005% and0.01% were about equally effective in reducing ocular itching over a 7minute time period as compared to vehicle alone.

Conjunctival redness was also subjectively assessed on a scale of 0 (noredness) to 4 (severe redness). As shown in FIG. 5, Fluticasone 0.001%,0.005% and 0.01% were about equally effective in reducing conjunctivalredness over a 20 minute period as compared to vehicle alone.

Lid swelling was subjectively assessed on a scale of 0 (no lid swelling)to 3 (severe lid swelling). As shown in FIG. 6, Fluticasone 0.001% and0.005% were each more effective than Fluticasone 0.01% at reducing lidswelling over a 20 minute period as compared to vehicle alone.

Nasal Congestion was subjectively assessed on a scale of 0 (nocongestion) to 4 (severe congestion). As shown in FIG. 7, Fluticasone0.001%, 0.005% and 0.01% were about equally effective in reducing nasalcongestion over a 30 minute period as compared to vehicle alone.

A summary of the results of the primary ocular endpoint assessments isshown in FIG. 8. As shown in FIG. 8, the reduction in conjunctivalredness by Fluticasone 0.005% and 0.01% and the reduction in lidswelling by Fluticasone 0.001% were each statistically significant(p<0.05).

Secondary Ocular Endpoints

Ciliary Redness, episcleral redness, chemosis and watery eyes wereassessed in each subject at visit 4B.

Ciliary redness was assessed on a scale of 0 (no redness) to 4 (severeredness). As shown in FIG. 9, Fluticasone 0.001%, 0.005% and 0.01% wereeach significantly effective in reducing ciliary redness over a 20minute period as compared to vehicle alone (p<0.05 for each Fluticasoneconcentration).

Episcleral redness was assessed on a scale of 0 (no redness) to 4(severe redness). As shown in FIG. 10, Fluticasone 0.001%, 0.005% and0.01% each reduce episcleral redness over a 20 minute period as comparedto vehicle alone.

Chemosis was assessed on a scale of 0 (none) to 4 (extreme). As shown inFIG. 11, Fluticasone 0.001%, 0.005% and 0.01% were each significantlyeffective in reducing chemosis over a 20 minute period.

Watery eyes were also subjectively assessed on a scale of 0 (not watery)to 4 (extremely watery). As shown in FIG. 12, Fluticasone 0.001% and0.05% were each more effective than Fluticasone 0.01% in reducing wateryeyes over a 20 minute period, as compared to vehicle alone.

A summary of the secondary ocular endpoints assessed is shown in FIG.13. As shown in FIG. 13, the reduction in ciliary redness by all threeconcentrations of Fluticasone, the reduction in episcleral redness byFluticasone 0.005%, and the reduction of watery eyes by Fluticasone0.05% were each statistically significant (p<0.05).

Secondary Nasal Endpoints

Rhinorrhea, ear or palate pruritis, nasal pruritis were assessed in eachsubject at visit 4B using a scale of 0 (none) to 4 (extreme) for eachendpoint.

As shown in FIGS. 14 and 16, Fluticasone 0.001%, 0.005% and 0.01% eachhad a clinically significant effect in reducing rhinorrhea and nasalpruritis, respectively, over a 20 minute period as compared to vehiclealone. Shown in FIG. 15, Fluticasone 0.001%, 0.005% and 0.01% were eachhad an effect in reducing ear and palate pruritis as compared to vehiclealone.

Total nasal scores were assessed on a scale of 0-16. As shown in FIG.17, Fluticasone 0.001%, 0.005% and 0.01%, each surprisingly had aclinically significant effect on total nasal score when administereddirectly to the eye of each subject. A summary of the nasal endpointsassessed is shown in FIGS. 18 and 19.

Safety

Intraocular pressure, drop comfort and adverse events such as blurryvision, conjunctival hemorrhage, dry eye, site pain and/or irritationand headache, were assessed for each subject.

Drop comfort was subjectively assessed on a scale of 0 (extremelycomfortable) to 10 (extremely uncomfortable) during visit 2 and visit 3.As shown in FIGS. 20 and 21, Fluticasone 0.01 was highly uncomfortableupon instillation as compared to Fluticasone 0.001% and 0.005%, and ascompared to vehicle alone. The comfort of Fluticasone 0.001% and 0.005%were comparable to the comfort of the vehicle control.

A summary of the total percentage of subjects who experienced adverseevents such as blurry vision, conjunctival hemorrhage, dry eye, sitepain and/or irritation, and headache, is shown in FIG. 22.

The effect of each concentration of Fluticasone on intraocular pressure(IOP) as compared to vehicle alone is shown in FIG. 23.

The results demonstrate that a single drop of either Fluticasone 0.001%,0.005% or 0.01% was effective to prevent both ocular and nasal symptomsassociated with allergic conjunctivitis, rhinitis andrhinoconjunctivitis.

However, when taking all primary and secondary endpoints intoconsideration, Fluticasone 0.005% was the most efficacious in relievingboth ocular and nasal symptoms, and was shown to be more comfortablethan Fluticasone 0.001% and Fluticasone 0.01%, with no adverse effect onintraocular pressure.

Example 3 An Evaluation of the Effects of Topical Cetirizine/FluticasoneOphthalmic Formulations on the Signs of Allergic Conjunctivitis Usingthe Murine Model of Ragweed-Induced Active Anaphylaxis

Seasonal allergic conjunctivitis (hay fever conjunctivitis) develops ina subset of atopic individuals (those with a genetic disposition ofhypersensitivity to allergens). The signs and symptoms of the conditionare elicited by airborne allergens (e.g. ragweed, tree and grasspollens, animal dander). Seasonal allergic conjunctivitis is the mostcommon form of ocular allergic disease and may account for up to 90% ofallergic disorders seen.

The most common and distressing ocular signs and symptoms associatedwith allergic conjunctivitis are itching and redness. Swelling, mucousdischarge and excessive tearing are frequently involved. In allergicconjunctivitis, airborne allergens presumably dissolve in the tear film,traverse the conjunctiva, and then bind with IgE antibodies attached tothe surface of the conjunctival mast cell to trigger an allergicresponse. This attachment results in mast cell degranulation and releaseof chemical mediators that lead to signs and symptoms of allergicdisease. Some of these substances, e.g. histamines and prostaglandins,directly affect blood vessels and nerves, whereas others influence themigration of inflammatory cells such as neutrophils, eosinophils andmacrophages, causing inflammation.

The major chemical mediator involved in producing ocular symptoms ishistamine. Several types of histamine have been identified in the humanconjunctiva. Stimulation of H1 receptors results mainly in itching whilestimulation of H2 receptors results largely in vasodilation (redness).However, studies with antihistamines known to be highly specific for H1receptors have suggested that H1 receptors may also have a secondaryeffect on redness.

The purpose of this study was to investigate the potential ofcetirizine/fluticasone combination formulations in preventing signs ofallergic conjunctivitis in a murine active anaphylaxis model. In thismodel, mice are systemically sensitized to short ragweed allergen (SRW)and then challenged by instilling SRW in the eyes. Therapeutic treatmentis given after sensitization but prior to topical challenge. Allergenspresent in the SRW preparation cross-link IgE antibodies bound toconjunctival mast cells causing degranulation and release of histamineand other allergic mediators, which in turn produce the characteristicsigns and symptoms of allergic conjunctivitis.

Four test formulations, containing combination 0.1% Cetirizine/0.005%Fluticasone (“low dose”), combination 0.25% Cetirizine/0.01% Fluticasone(“high dose”), 0.1% Cetirizine or 0.005% Fluticasone, were compared withvehicle alone (1% Polyethylene Glycol 400, NF; 0.2% Dibasic SodiumPhosphate, Anhydrous, USP; 0.25% Hypromellose, USP; 0.1% Polysorbate 80,NF; 1.8% Glycerin, USP; 0.025% Edetate Disodium, USP; 0.01% BenzalkoniumChloride, NF (pH 7.0)) and two commercial positive controls, Pred Forte®(prednisolone acetate 1%) and Pataday® (olopatadine 0.2%).

Systemic sensitization to short ragweed allergen (SRW) was induced byinjecting SRW plus alum adjuvant systemically into Balb/c mice (Day 1),and by administration of topical SRW eyedrops on days 19-21. Topicalocular drug treatment was administered daily on days 19-21 after SRWinjection. After 3 days of treatment, the animals were assessed forsigns of allergic conjunctivitis in response to challenge with topicalSRW administration. Clinical assessments included conjunctivalhyperemia, chemosis, discharge and lid swelling, each gradedbiomicroscopically on a 0-4 severity scale.

After 3 days of drug treatment, the animals treated with the combination0.1% Cetirizine/0.005% Fluticasone demonstrated the least severity inthree clinical signs (conjunctival hyperemia, chemosis, and lidswelling) as compared Cetirizine or Fluticasone alone or as compared tomost other treatment groups. Cetirizine or Fluticasone alone produced nosignificant treatment effects.

The reduction in clinical signs in response to SRW challenge after 3days of treatment with the combination 0.1% Cetirizine/0.005%Fluticasone was statistically significantly lower than Fluticasone alonefor hyperemia (p≦0.001), chemosis (p≦0.01), lid swelling (p≦0.03) andtotal clinical score (p≦0.01); and than Cetirizine alone for chemosis(p≦0.05). Additionally, statistical significance was almost achievedagainst Cetirizine alone for total clinical score (p=0.06).Surprisingly, the reduction with the combination was more than couldhave been expected from the efficacy of the individual components.

Furthermore, the combination of 0.1% Cetirizine/0.005% Fluticasoneperformed better than either the steroid (Pred Forte®) or antihistamine(Pataday®), leading commercial products used as positive controls inthis study. Additionally, the higher concentration of the combination(0.25% Cetirizine/0.01% Fluticasone) was minimally effective in thismodel under this dosing regimen and conditions.

The results of this study indicate that a substantial clinical benefitmay be achieved with the combination of low dose Cetirizine/Fluticasoneover its individual components, over the high dose combination and overexisting lead commercial products.

Experimental Design:

TABLE 3 Schedule of Procedures Procedure Day 0 Day 19 Day 20 Day 21 Day26 Ocular Exam X X SRW Injection X Topical SRW X X X Dosing X X XChallenge X Behavior X Observations Photographs X Euthanasia X Eye XEnucleations

Sensitization

On Day 0, animals received injections containing a suspension of 50 μgof short ragweed allergen (SRW, Greer, Lenoir, N.C., USA) in 25 μL alum(aluminum hydroxide gel). Additional sensitization was achieved bytopical dosing with 1 mg SRW in 5 μl PBS on Days 19 and 20 afterinjection.

Dosing

On days 19 through 21, topical treatment was administered once daily.Mice were dosed topically to the central cornea using a calibratedmicropipette, with a 5 μL drop of treatment in each eye. The dose groupsare outlined in the table below:

Challenge

On day 21, twenty minutes after ocular treatment dosing, animals werechallenged with topical doses of 1000 μg SRW suspension in 5 μl PBS ineach eye. SRW was prepared fresh and used within 3 hours of mixing, andmixed well before administration to ensure homogeneity.

TABLE 4 Test/Control Articles Group Number of Volume per Number AnimalsTest Article Dose 1 8 0.1% Cetirizine/0.005% 5 μL Fluticasone 2 8 0.25%Cetirizine/0.01% 5 μL Fluticasone 3 8 0.1% Cetirizine 5 μL 4 8 0.005%Fluticasone 5 μL 5 8 Olopatadine HCl 0.2% 5 μL (Pataday ®) 6 8 Pred.acetate 1% 5 μL (Pred Forte ®) 7 8 Vehicle Control 5 μL

Experimental Procedures:

Ophthalmic exams were performed at baseline (study entry) according tothe Ocular Irritation Grading Scale to verify that the eyes did notexhibit any signs of ocular irritation.

Ophthalmic exams were also performed on day 21, 15 minutes after theallergen challenge. Exams were performed under dissecting microscope,and included conjunctival hyperemia, chemoosis, tear/discharge, and lidswelling, each graded on a 0-4 scale (0.5 units were allowed for anyocular score).

There were no abnormal ophthalmic findings in any animals used in thestudy and no unscheduled deaths during this study.

Tissue Collections/Preservation and Statistical Analysis

Immediately after euthanasia (CO₂ inhalation and cervical dislocation),eyes and surrounding lid tissue was collected and placed immediately in4% paraformaldehyde for 24 hours, after which they were transferred to70% ethanol for storage prior to paraffin embedding and sectioning forhistology.

Both eyes of each animal were averaged and all animals within a groupwere averaged to obtain an average score for each treatment group foreach measurement parameter. Statistically significant differencesbetween groups were determined using the 2-tailed, 2-sample t-test.

Results

Day 0 baseline exams ensured that all mice were free of any redness,swelling, and tearing.

After 3 days of drug treatment, the animals treated with the combination0.1% Cetirizine/0.005% Fluticasone demonstrated the least severity inthree of the four clinical signs (conjunctival hyperemia, chemosis, andlid swelling) as compared to Cetirizine or Fluticasone alone, and ascompared to most other treatment groups. Total clinical score (sum ofscores of all clinical signs in both eyes) was lowest in the 0.1%Cetirizine/0.005% Fluticasone combination group as compared to all othertreatment groups. Cetirizine or Fluticasone alone produced nosignificant treatment effects.

The reduction in clinical signs in response to SRW challenge after 3days of treatment with the combination 0.1% Cetirizine/0.005%Fluticasone was statistically significantly lower than Fluticasone alonefor hyperemia (p≦0.001), chemosis (p≦0.01), lid swelling (p≦0.03) andtotal clinical score (p≦0.01); and than Cetirizine alone for chemosis(p≦0.05). Borderline significance was achieved against Cetirizine alonefor total clinical score (p=0.06).

Surprisingly, the high dose combination of 0.25% Cetirizine/0.01%Fluticasone was less effective than the low dose combination in thismodel for all clinical signs, with the exception of an effect onchemosis. The only statistically significant decrease in any clinicalsign after high dose combination treatment was for chemosis as comparedto Fluticasone alone (p≦0.05).

Under these treatment conditions (3 days of once-daily dosing), neitherof the positive control test articles, commercially available Pred Forte(prednisolone acetate 1%), a steroid, or Pataday (olopatadine 0.2%), theleading anti-histamine, produced significant treatment effects, with theexception of a decrease in chemosis produced by olopatadine, comparableto the effect seen with the combination 0.1% Cetirizine/0.005%Fluticasone. This chemosis effect was statistically significantlydifferent from Fluticasone alone (p≦0.05).

The results are summarized in Table 5 below and in FIGS. 24-28.

TABLE 5 Summary of Results Conjunctival Total Clinical HyperemiaChemosis Discharge Lid Edema Score Treatment Group Average SEM Avg SEMAvg SEM Avg SEM Avg SEM 0.1% Cetirizine/ 1.00 0.11 1.22 0.11 1.38 0.121.56 0.09 10.31 0.66 0.005% Fluticasone 0.25% Cetirizine/ 1.53 0.14 1.280.15 1.41 0.18 1.69 0.27 11.63 1.09 0.01% Fluticasone 0.1% Cetirizine1.34 0.17 1.59 0.14 1.66 0.21 1.78 0.15 12.75 1.00 0.005% Fluticasone1.78 0.15 1.66 0.09 1.34 0.15 1.97 0.14 13.50 0.80 Olopatadine HCl 1.470.25 1.19 0.19 1.53 0.15 1.63 0.16 11.63 1.34 0.2% (Pataday ®) Pred.acetate 1% 1.61 0.14 1.50 0.12 1.79 0.26 1.93 0.28 12.86 1.43 (PredForte ®) Vehicle Control 1.53 0.20 1.38 0.13 1.56 0.24 1.94 0.18 12.811.19

Conclusion:

The low dose combination of 0.1% Cetirizine/0.005% Fluticasone was themost effective at preventing signs of allergic conjunctivitis in themurine ragweed sensitization model. Neither component of the combinationused alone, at the same concentrations, produced a substantial treatmenteffect. The low-dose combination, assessed after 3 days of treatment and15 minutes after ragweed challenge, reduced conjunctival hyperemia,chemosis, and lid swelling, and resulted in the lowest clinical summaryscore of any of the treatment arms, including the cetirizine orfluticasone alone, and commercial ophthalmics Pataday® and Pred Forte®.

Surprisingly, the higher concentration of the combination (0.25%Cetirizine/0.01% Fluticasone) was minimally effective in this modelunder this dosing regimen and conditions. These results indicate thatthe 0.1% Cetirizine/0.005% Fluticasone formulation has excellentpotential for the prevention and treatment of allergic conjunctivitisand that a substantial clinical benefit might be achieved with thecombination of Cetirizine/Fluticasone over either medication used alone.

In summary, the results consistently favored 0.1% cetirizine/0.005%fluticasone combination (low dose) over both the individual componentsalone as well as the high dose combination (0.25% cetirizine/0.01%fluticasone), which is surprising because one skilled in the art mightexpect the higher dose formulation to work at least equally well if notbetter than the low dose formulation. The low dose combination alsoworked better than would be expected from the results of the individualcomponents, thus showed a synergistic effect between the cetirizine andfluticasone

Additionally, the low dose combination worked better than well known,leading ocular antihistamines and ocular steroid—these results confirmthe effectiveness of the specific combination of cetirizine/fluticasoneat the preferred low dose concentrations.

Lastly, the low dose combination was more efficacious than itscomparison arms across all endpoints, including total ocular compositescore.

Example 4 Comfort Profile of Cetirizine/Fluticasone Formulation

The purpose of this study was to assess the comfort of a 0.1%cetirizine/0.005% fluticasone (low dose) formulation and a 0.25%cetirizine/0.01% fluticasone (high dose) formulation upon instillationin the human eye (N=5). The low dose and high dose combinations wereeach formulated in 1% Polyethylene Glycol 400, NF; 0.2% Dibasic SodiumPhosphate, Anhydrous, USP; 0.25% Hypromellose, USP; 0.1% Polysorbate 80,NF; 1.8% Glycerin, USP; 0.025% Edetate Disodium, USP; 0.01% BenzalkoniumChloride, NF, as reflected in Tables 6 and 6 below:

TABLE 6 0.005% Fluticasone Propionate/0.1% Cetirizine OphthalmicSuspension Concen- tration Ingredient Purpose 0.005%  FluticasonePropionate, USP Active, Steroid  1% Polyethylene Glycol 400, NF Carrier0.2% Dibasic Sodium Phosphate, Buffer Anhydrous, USP 0.1188%  Cetirizine Dihydrochloride, Active, Antihistamine Ph. Eur. 0.25% Hypromellose, USP Viscosity agent 0.1% Polysorbate 80, NF Surfactant1.8% Glycerin, USP Tonicity Agent 0.025%  Edetate Disodium, USPChelating Agent 0.01%  Benzalkonium Chloride, N.F. Preservative q.s.Sterile Purified Water Vehicle

TABLE 7 0.01% Fluticasone Propionate/0.25% Cetirizine OphthalmicSuspension Concen- tration Ingredient Purpose 0.01% FluticasonePropionate, USP Active, Steroid   2% Polyethylene Glycol 400, NF Carrier 0.2% Dibasic Sodium Phosphate, Buffer Anhydrous, USP 0.297%  CetirizineDihydrochloride, Active, Antihistamine Ph. Eur. 0.25% Hypromellose, USPViscosity agent  0.1% Polysorbate 80, NF Surfactant  1.2% Glycerin, USPTonicity Agent 0.025%  Edetate Disodium, USP Chelating Agent 0.01%Benzalkonium Chloride, N.F. Preservative q.s. Sterile Purified WaterVehicle

Each of the formulations in Tables 5 and 6 had a pH 7.0 and anosmolality of 300 mOsm/kg.

One drop of masked study medication was instilled in each eye andsubjects were asked to assess the comfort of the drop on a subjectivescale of 0 to 10 (0=comfortable, 10=very uncomfortable (Note: The mostuncomfortable commercially available allergy drop=4). The results areshown in FIG. 29. Both the low dose and high dose formulations were welltolerated (average comfort score <3) and were found to be morecomfortable than the formulation comprising 0.005% fluticasone alone asthe only active agent, which had an osmolality of 900 mOsm/kg (averagecomfort score ˜3; See FIGS. 20-21, Example 2).

Example 5 Stability of 0.10% Cetirizine Formulation and CombinedCetirizine/Fluticasone Formulations

Tables 8-9 below show that a 0.1% formulation of cetirizine was stablefor at least three months both at room temperature (Table 6) and athigher temperatures (Table 7).

Tables 10-11 below show that a 0.1% cetirizine/0.005% fluticasoneformulation (in 1% Polyethylene Glycol 400, NF; 0.2% Dibasic SodiumPhosphate, Anhydrous, USP; 0.25% Hypromellose, USP; 0.1% Polysorbate 80,NF; 1.8% Glycerin, USP; 0.025% Edetate Disodium, USP; 0.01% BenzalkoniumChloride, NF (pH 7.0); i.e., the formulation listed in Table 5) wasstable for at least one month at both room temperature (Table 8) and athigher temperature (Table 9) when stored upright.

Tables 12 and 13 show that a 0.25% cetirizine/0.01% fluticasoneformulation (in 1% Polyethylene Glycol 400, NF; 0.2% Dibasic SodiumPhosphate, Anhydrous, USP; 0.25% Hypromellose, USP; 0.1% Polysorbate 80,NF; 1.8% Glycerin, USP; 0.025% Edetate Disodium, USP; 0.01% BenzalkoniumChloride, NF (pH 7.0); i.e., the formulation listed in Table 6) wasstable for at least one month at room temperature (Table 10) and at ahigher temperature (Table 11) when stored upright.

Cetirizine and fluticasone concentrations were quantified by highpressure liquid chromatography (HPLC). Impurities are shown as “relativeretention time” or RRT in the table, which relates the unknown peak tothe elution time of the parent peak, cetirizine (or fluticasone). At notime did the total impurities exceed 1%. Sterility, particulate matter,and preservative efficacy were determined only at the initial time pointbecause these should remain unchanged provided that the sealed containeris not compromised.

The data herein demonstrates cetirizine and cetirizine/fluticasoneformulations that are stable without the inclusion of a cyclodextrin orother solubilizing compound. Without intending to be bound by anytheory, the stability was achieved by minimizing/excluding the additionof counter ions or metal based buffers that could promote saltformation, precipitation, or metal based degradation.

TABLE 8 Cetirizine 0.10%/Benzalkonium Chloride 0.01% (w/v) OphthalmicSolution Stability Testing: 25° C./60% RH (QA Oct. 13, 2008) Lot #:04262008@18 Initial 1 Month 2 Month 3 Month Test Limits/SpecificationJun. 9, 2008 Jul. 9, 2008 Aug. 11, 2008 Sep. 10, 2008 Appearance Clearand colorless Conforms: Clear, Conforms: Clear, Conforms: Clear,Conforms: Clear, (Contents) to slightly Colorless Solution ColorlessSolution Colorless Solution Colorless Solution yellow solutionAppearance No leakage Conforms: No Conforms: No Conforms: No Conforms:No (Container Integrity) observed, leakage, container leakage, containerleakage, container leakage, container container intact intact intactintact intact Assay: Cetirizine NLT 90.0% and 99.2% LC 99.5% LC  99.7%LC 99.4% LC Label Claim: 0.10% NMT 110.0% (w/v) (equivalent to of LabelClaim (LC) Cetirizine dihydrochloride 0.1188%) Assay of KetotifenAbsence of Active Not Detected Not Detected Not Detected Not DetectedImpurities (Total, Report individual ≧0.05% RRT @ 0.93: 0.06% RRT @0.90: 0.06% RRT @ 0.67: 0.07% RRT @ 0.63: 0.09% Ketotifen impurities,Report Total RRT @ 1.1: 0.15% RRT @ 1.60: 0.06% RRT @ 0.91: 0.06% RRT @0.92: 0.05% Cetirizine impurities) Total: 0.2% RRT @ 2.11: 0.06% RRT @1.10: 0.05% RRT @ 1.08: 0.05% Total: 0.2% RRT @ 1.11: 0.09% RRT @ 1.10:0.09% RRT @ 2.33: 0.06% RRT @ 1.56: 0.08% Total: 0.30%% Total: 0.40%%Assay: Benzalkonium NLT 85.0% and 99.4% LC 94.6% LC 100.0% LC 94.7% LCChloride NMT 115% Label Claim: 0.01% of Label Claim (w/v) pH 5.5 ± 0.55.7 6.0 6.0 5.9 Osmolality Report 253 mOsm/Kg · H₂0 253 mOsm/Kg · H₂0253 mOsm/Kg · H₂0 252 mOsm/Kg · H₂0 Sterility Meets USP Criteria PassParticulate Matter Number of particles with Pass diameter of: ≧10 μm:NMT 50/mL ≧25 μm: NMT 5/mL ≧50 μm: NMT 2/mL Antimicrobial Report PassPreservative Efficacy

TABLE 9 Cetirizine 0.10%/Benzalkonium Chloride 0.01% (w/v) OphthalmicSolution Stability Testing: 40° C./75% RH (QA Oct. 13, 2008) (Lot #:04262008@18) Initial 1 Month 2 Month 3 Month Test Limits/SpecificationJun. 9, 2008 Jul. 9, 2008 Aug. 11, 2008 Sep. 10, 2008 Appearance Clearand colorless Conforms: Clear, Conforms: Clear, Conforms: Clear,Conforms: Clear, (Contents) to slightly Colorless Solution ColorlessSolution Colorless Solution Colorless Solution yellow solutionAppearance No leakage Conforms: No Conforms: No Conforms: No Conforms:No (Container Integrity) observed, leakage, container leakage, containerleakage, container leakage, container container intact intact intactintact intact Assay: Cetirizine NLT 90.0% and 99.2% LC 99.6% LC 100.1%LC 99.4% LC Label Claim: 0.10% NMT 110.0% (w/v) (equivalent to of LabelClaim (LC) Cetirizine dihydrochloride 0.1188%) Assay of KetotifenAbsence of Active Not Detected Not Detected Not Detected Not DetectedImpurities (Total, Report individual ≧0.05% RRT @ 0.93: 0.06% RRT @0.90: 0.06% RRT @ 0.67: 0.34% RRT @ 0.63: 0.44% Ketotifen impurities,Report Total RRT @ 1.1: 0.15% RRT @ 2.11: 0.06% RRT @ 0.78: 0.05% RRT @0.92: 0.05% Cetirizine impurities) Total: 0.2% Total: 0.1% RRT @ 0.91:0.06% RRT @ 1.10: 0.09% RRT @ 1.10: 0.05% Total: 0.6% RRT @ 1.11: 0.09%RRT @ 2.33: 0.06% Total: 0.70%% Assay: Benzalkonium NLT 85.0% and 99.4%LC 92.9% LC  99.1% LC 96.8% LC Chloride NMT 115% Label Claim: 0.01% ofLabel Claim (w/v) pH 5.5 ± 0.5 5.7 6.0 5.9 5.7 Osmolality Report 253mOsm/Kg · H₂0 254 mOsm/Kg · H₂0 254 mOsm/Kg · H₂0 255 mOsm/Kg · H₂0Sterility Meets USP Criteria Pass Particulate Matter Number of particleswith Pass diameter of: ≧10 μm: NMT 50/mL ≧25 μm: NMT 5/mL ≧50 μm: NMT2/mL Antimicrobial Report Pass Preservative Efficacy

TABLE 10 0.005% Fluticasone Propionate/0.1% Cetirizine OphthalmicSuspension Stability Testing: 25° C./40% RH (Lot Number: Ora091202.V1)Test Initial 1 Week 2 Week 2 Week 1 Month Date Pulled Dec. 15, 2009 Jan.04, 2010 Inverted Dec. 21, 2009 Dec. 28, 2009 Upright Jan. 13, 2010Specification Orientation Inverted Orientation Inverted OrientationOrientation Upright Orientation Appearance Report Results Clear, Clear,Colorless, no Clear, Colorless, no NT Slightly Turbid (Solution)Colorless, ppt. ppt. Solution no ppt. Appearance No leakage observed, NTNo leakage No leakage observed, NT No leakage observed, (Container)container intact observed, container intact container intact containerintact Fluticasone 90%-110% Label 95.1% LC 98.6% LC 89.4% LC* 102.4% LC99.6% LC Propionate Claim Assay Fluticasone Report individual RRT 0.19:RRT 0.19: 0.50% RRT 0.09: 0.06% AUC RRT 0.07: RRT 0.12: 0.39% AUCRelated % AUC, 0.75% AUC AUC RRT 0.10: 0.14% 0.25% AUC RRT 0.14: 0.63%AUC Substances Report total, % AUC RRT 0.36: RRT 0.36: 0.40% AUC RRT0.09: RRT 0.29: 0.41% AUC 0.35% AUC AUC RRT 0.12: 0.72% 0.06% AUC RRT0.34: 0.10% AUC Total: 1.07% RRT 0.66: 0.24% AUC RRT 0.10: Total: 1.53%AUC AUC AUC RRT 0.27: 0.49% 0.16% AUC RRT 0.93: 0.07% AUC RRT 0.12: AUCRRT 0.33: 0.18% 0.53% AUC Total: 1.21% AUC RRT 0.27: RRT 0.52: 0.05%0.46% AUC AUC RRT 0.33: RRT 0.61: 0.29% 0.14% AUC AUC Total: 1.6% RRT0.76: 0.23% AUC RRT 0.88: 0.27% AUC Total: 2.43% Cetirizine 90%-110%Label 98.6% LC 97.2% LC 98.0% LC NT 96.5% LC Assay Claim CetirizineReport individual RRT 0.96: 0.5% RRT 0.96: 0.05% RRT 0.96: 0.05% NT RRT1.13: 0.53% AUC Related % AUC, AUC AUC AUC Total: 0.53% AUC SubstancesReport total, % AUC RRT 1.13: RRT 1.13: 0.18% RRT 1.13: 0.19% 0.08% AUCAUC AUC Total: 0.13% Total: 0.23% Total: 0.24% Benzalkonium 50%-150%Label 99.5% LC NT NT NT 101.0% LC chloride Assay Claim Disodium 70%-120%Label 95.8% LC NT NT NT 91.2% LC Edetate Claim pH 6.5-7.8 7.1 7.0 7.0 NT7.0 Osmolality Report results 291 mOsm/Kg 290 mOsm/Kg 291 mOsm/Kg NT 290mOsm/Kg RH = relative humidity, LC = label claim, AUC = area undercurve, NT = not tested. *The low assay values were attributed to theinverted orientation in which the stability samples were stored. Samplesstored in the upright orientation were tested at the 2-week time pointand subsequent time points, as reflected in the data shown.

TABLE 11 0.005% Fluticasone Propionate/0.1% Cetirizine OphthalmicSuspension Stability Testing: 40° C./NMT 25% RH (Lot Number:Ora091202.V1) Initial 2 Week 2 Week 1 Month Date Pulled Dec. 15, 2009Dec. 28, 2009 Jan. 04, 2010 Jan. 13, 2010 Test Specification InvertedOrientation Inverted Orientation Upright Orientation Upright OrientationAppearance Report Results Clear, Colorless, Clear, Colorless, NTSlightly turbid (Solution) no ppt. no ppt. solution Appearance Noleakage observed, NT No leakage observed, NT No leakage observed,(Container) container intact Container intact container intactFluticasone 90%-110% Label 95.1% LC 58.4% LC* 103.2% LC 101.4% LCPropionate Assay Claim Fluticasone Related Report individual RRT 0.19:0.75% AUC RRT 0.09: 0.66% AUC RRT 0.07: 0.26% AUC RRT 0.11: 0.69% AUCSubstances % AUC, RRT 0.36: 0.35% AUC RRT 0.10: 0.59% AUC RRT 0.09:0.52% AUC RRT 0.14: 0.59% AUC Report total, % AUC Total: 1.07% AUC RRT0.12: 0.72% AUC RRT 0.10: 0.13% AUC RRT 0.29: 0.35% AUC RRT 0.28: 0.72%AUC RRT 0.12: 0.35% AUC RRT 0.34: 0.60% AUC RRT 0.33: 1.12% AUC RRT0.27: 0.43% AUC Total: 2.23% AUC RRT 0.45: 0.20% AUC RRT 0.33: 0.19% AUCRRT 0.49: 0.11% AUC RRT 0.76: 0.06% AUC RRT 0.53: 0.14% AUC Total: 2.02%RRT 0.60: 0.14% AUC RRT 0.76: 0.31% AUC RRT 0.88: 0.49% AUC Total: 5.20%Cetirizine Assay 90%-110% Label 98.6% LC 97.9% LC NT  96.8% LC ClaimCetirizine Related Report individual RRT 0.96: 0.5% AUC RRT 1.13: 0.48%AUC NT RRT 1.13: 0.82% AUC Substances % AUC, RRT 1.13: 0.08% AUC Total:0.48% Total: 0.82% AUC Report total, % AUC Total: 0.13% Benzalkonium50%-150% Label 99.5% LC NT NT 101.3% LC chloride Assay Claim DisodiumEdetate 70%-120% Label 95.8% LC NT NT  91.0% LC Claim pH 6.5-7.8 7.1 7.0NT 7.0 Osmolality Report results 291 mOsm/Kg 293 mOsm/Kg NT 291 mOsm/KgRH = relative humidity, LC = label claim, AUC = area under curve, NT =not tested. *The low assay values were attributed to the invertedorientation in which the stability samples were stored. Samples storedin the upright orientation were tested at the 2-week time point andsubsequent time points, as reflected in the data shown.

TABLE 12 0.01% Fluticasone Propionate/0.25% Cetirizine OphthalmicSuspension Stability Testing: 25° C./40% RH (Lot Number: Ora091130.V1)Test Initial 1 Week 2 Week 2 Week 1 Month Date Pulled Jan. 04, Dec. 15,2009 2010 Inverted Dec. 21, 2009 Dec. 28, 2009 Upright Jan. 13, 2010Specification Orientation Inverted Orientation Inverted OrientationOrientation Upright Orientation Appearance Report Results Clear, Clear,colorless, no ppt Clear, colorless, no ppt NT Slightly turbid solution(Solution) Colorless, no ppt. Appearance No leakage observed, NT Noleakage observed, No leakage observed, NT No leakage observed,(Container) container intact container intact container intact containerintact Fluticasone 90%-110% Label 96.9% LC 98.9% LC 79.0% LC* 99.6% LC99.2% LC Propionate Claim Assay Fluticasone Report individual RRT 0.18:RRT 0.19: 0.61% AUC RRT 0.06: 0.36% AUC RRT 0.06: RRT 0.11: 0.46% AUCRelated % AUC, 0.82% AUC RRT 0.35: 0.47% AUC RRT 0.09: 0.38% AUC 0.49%AUC RRT 0.13: 0.74% AUC Substances Report total, % AUC RRT 0.35: RRT0.67: 0.43% AUC RRT 0.12: 0.82% AUC RRT 0.09: RRT 0.29: 0.50% AUC 0.40%AUC Total: 1.51% RRT 0.27: 0.67% AUC 0.38% AUC Total: 1.17% AUC Total:1.22% RRT 0.33: 0.20% AUC RRT 0.12: RRT 0.44: 0.31% AUC 0.66% AUC RRT0.51: 0.42% AUC RRT 0.27: RRT 0.60: 0.27% AUC 0.53% AUC RRT 0.76: 1.04%AUC RRT 0.36: RRT 0.88: 1.48% AUC 0.20% AUC Total: 6.14% RRT 0.52: 0.09%AUC Total: 2.35% Cetirizine 90%-110% Label 99.3% LC 97.3% LC 98.7% LC NT97.2% LC Assay Claim Cetirizine Report individual RRT 0.96: RRT 0.96:0.05% AUC RRT 0.96: 0.05% AUC NT RRT 1.13: 0.75% AUC Related % AUC,0.05% AUC RRT 1.13: 0.31% AUC RRT 1.13: 0.32% AUC Total: 0.75% AUCSubstances Report total, % AUC RRT 1.13: Total: 0.36% Total: 0.37% 0.14%AUC Total: 0.19% Benzalkonium 50%-150% Label 96.7% LC NT NT NT 100.6% LCchloride Assay Claim Disodium 70%-120% Label 92.9% LC NT NT NT 89.7% LCEdetate Claim pH 6.5-7.8 7.1 7.1 7.1 NT 7.1 Osmolality Report results272 mOsm/Kg 273 mOsm/Kg 274 mosm/Kg NT 273 mOsm/Kg RH = relativehumidity, LC = label claim, AUC = area under curve, NT = not tested.*The low assay values were attributed to the inverted orientation inwhich the stability samples were stored. Samples stored in the uprightorientation were tested at the 2-week time point and subsequent timepoints, as reflected in the data shown.

TABLE 13 0.01% Fluticasone Propionate/0.25% Cetirizine OphthalmicSuspension Stability Testing: 40° C./NMT 25% RH (Lot Number:Ora091130.V1) Test Initial 1 Week 2 Week 2 Week 1 Month Date Pulled Jan.04, Dec. 15, 2009 2010 Inverted Dec. 21, 2009 Dec. 28, 2009 Upright Jan.13, 2010 Specification Orientation Inverted Orientation InvertedOrientation Orientation Upright Orientation Appearance Report ResultsClear, Clear, colorless, no ppt Clear, colorless, no ppt NT Slightlyturbid solution (Solution) Colorless, no ppt. Appearance No leakageobserved, NT No leakage observed, No leakage observed, NT No leakageobserved, (Container) container intact container intact container intactcontainer intact Fluticasone 90%-110% Label 96.9% LC 98.5% LC 51.4% LC*100.4% LC 98.9% LC Propionate Claim Assay Fluticasone Report individualRRT 0.18: RRT 0.19: 0.47% AUC RRT 0.09: 1.09% AUC RRT 0.06: RRT 0.11:0.94% AUC Related % AUC, 0.82% AUC RRT 0.35: 0.49% AUC RRT 0.10: 0.43%AUC 0.44% AUC RRT 0.13: 0.71% AUC Substances Report total, % AUC RRT0.35: RRT 0.66: 0.38% AUC RRT 0.12: 0.73% AUC RRT 0.09: RRT 0.28: 0.08%AUC 0.40% AUC Total: 1.34% RRT 0.27: 0.97% AUC 0.93% AUC Total: 1.73%AUC Total: 1.22% RRT 0.32: 0.56% AUC RRT 0.12: RRT 0.44: 0.24% AUC 0.53%AUC RRT 0.51: 0.67% AUC RRT 0.27: RRT 0.60: 0.30% AUC 0.52% AUC RRT0.76: 0.99% AUC RRT 0.31: RRT 0.88: 1.32% AUC 0.07% AUC Total: 7.54% RRT0.36: 0.17% AUC Total: 2.66% Cetirizine 90%-110% Label 99.3% LC 97.1% LC98.6% LC NT 96.7% LC Assay Claim Cetirizine Report individual RRT 0.96:RRT 0.46: 0.08% AUC RRT 0.46: 0.08% AUC NT RRT 1.13: 0.96% AUC Related %AUC, 0.05% AUC RRT 1.13: 0.69% AUC RRT 1.13: 0.70% AUC Total: 0.96% AUCSubstances Report total, % AUC RRT 1.13: Total: 0.77% Total: 0.78% 0.14%AUC Total: 0.19% Benzalkonium 50%-150% Label 96.7% LC NT NT NT 98.7% LCchloride Assay Claim Disodium 70%-120% Label 92.9% LC NT NT NT 90.4% LCEdetate Claim pH 6.5-7.8 7.1 7.1 7.1 NT 7.0 Osmolality Report results272 mOsm/Kg 273 mOsm/Kg 272 mOsm/Kg NT 274 mOsm/Kg RH = relativehumidity, LC = label claim, AUC = area under curve, NT = not tested.*The low assay values were attributed to the inverted orientation inwhich the stability samples were stored. Samples stored in the uprightorientation were tested at the 2-week time point and subsequent timepoints, as reflected in the data shown.

Example 6 Clinical Efficacy of Cetirizine/Fluticasone Formulations

The purpose of this example was to evaluate the efficacy of cetirizine0.1%/fluticasone 0.005% ophthalmic suspension compared to cetirizine0.1% ophthalmic suspension, fluticasone 0.005% ophthalmic suspension andvehicle in the prevention of the signs and symptoms of allergicconjunctivitis in a modified CAC model.

A multi-center, double-masked, randomized, vehicle-controlled, paralleltreatment comparison study was conducted on approximately 80 subjectsage 10 and older with a history of allergic conjunctivitis, and with abest corrected visual acuity of 0.7 logMAR or better in each eye. Theconjunctival allergen challenge (CAC) model was used for screeningpurposes and to reproducibly exacerbate subject's signs and symptoms ofallergic conjunctivitis.

The study was conducted during allergy season and comprised 4 visitsover a period of 3 weeks including a 1-week period of QD dosing withassigned study medication. A modification of the CAC model thatincorporates 3 CACs over a 2-day period was used to evaluate theeffectiveness of the study medication on both the acute and the chroniccomponents of the allergic reaction. The drug challenge CAC sequence wascarried out prior to, and following, 1-week of QD dosing with assignedstudy medication.

The study comprised 4 visits conducted over a period of approximately 3weeks.

Summary of Visit Schedule

Visit 1 (Day −1): Allergen titration

Visit 2A (Day 0): Allergen confirmation;

Visit 2B (Day 0): 8 hour re-challenge; Randomization; In-office dose

-   -   Subjects self-administer assigned study medication, QD (days        1-12)

Visit 3 (Day 13): In-office dose 15 mins prior to challenge;

Visit 4A (Day 14): In-office dose 30 mins after challenge;

Visit 4B (Day 14): 8 hour re-challenge; Exit

Visit 1 (Day −1), Allergen Titration: subjects meeting all entrycriteria were challenged with particular allergens in increasingconcentrations. Within 10 minutes of each allergen instillation,conjunctival redness and ocular itching were assessed using a 9-pointscale (0 to 4, with 0.5-unit increments allowed). Any subject who failedto demonstrate an adequate CAC reaction at baseline was excluded fromthe study.

Visit 2 (Day −0), Visit 2 was divided into 2 separate visits 8 hoursapart.

Visit 2A, Allergen Confirmation: the CAC was repeated to verify thereproducibility of the ocular itching and conjunctival rednessresponses. Itching was subject-evaluated at 3, 5, and 7 minutespost-CAC. Redness and chemosis were graded by the investigator at 7, 15and 20 minutes post-CAC. The subject graded lid swelling, watery eyes,rhinorrhea, nasal pruritis, nasal congestion, and ear or palate pruritisat 7, 15, and 20 minutes post-CAC.

Visit 2B, Rechallenge/Randomization: the CAC was repeated after theinitial CAC at Visit 2A. Itching was subject-evaluated at 3, 5, and 7minutes post-CAC. Redness and chemosis were graded by the investigatorat 7, 15 and 20 minutes post-CAC. The subject graded lid swelling,watery eyes, rhinorrhea, nasal pruritis, nasal congestion, and ear orpalate pruritis at 7, 15, and 20 minutes post-CAC. Any subject whofailed to demonstrate an adequate CAC reaction at baseline was excludedfrom the study.

Qualified subjects were randomized, in a 1:1:1:1 ratio, into 4groups: 1) cetirizine 0.1%/fluticasone 0.005% ophthalmic suspension(combo), 2) cetirizine 0.1% ophthalmic suspension, 3) fluticasone 0.005%ophthalmic suspension, 4) Vehicle of combo (placebo). Subjects receivedthe first dose of study medication at approximately 30 minutes post-CAC.Subjects continued QD dosing at home for the 2 weeks between Visit 2 andVisit 3. Subjects recorded ocular and nasal symptoms in daily diaries.

Visit 3 (Day 13), Drug Efficacy CAC: assigned study medication wasinstilled in-office minutes prior to CAC. Itching was subject-evaluatedat 3, 5, and 7 minutes post-CAC. Redness and chemosis were graded by theinvestigator at 7, 15 and 20 minutes post-CAC. The subject graded lidswelling, watery eyes, rhinorrhea, nasal pruritis, nasal congestion, andear or palate pruritis at 7, 15, and 20 minutes post-CAC.

Visit 4 (Day 14), Visit 4 was divided into 2 separate visits.

Visit 4A, Drug Efficacy CAC: The CAC was repeated after the Visit 3 doseof assigned study medication. Itching was subject-evaluated at 3, 5, and7 minutes post-CAC. Redness and chemosis were graded by the investigatorat 7, 15 and 20 minutes post-CAC. The subject graded lid swelling,watery eyes, rhinorrhea, nasal pruritis, nasal congestion, and ear orpalate pruritis at 7, 15, and 20 minutes post-CAC.

Visit 4B, 8-hour Rechallenge: the CAC was repeated after the initial CACat Visit 4A. Itching was subject-evaluated at 3, 5, and 7 minutespost-CAC. Redness and chemosis were graded by the investigator at 7, 15and 20 minutes post-CAC. The subject graded lid swelling, watery eyes,rhinorrhea, nasal pruritis, nasal congestion, and ear or palate pruritisat 7, 15, and 20 minutes post-CAC.

Primary Efficacy Endpoints

The primary efficacy endpoints were ocular itching and conjunctivalredness, evaluated at Visit 3, Visit 4A, and Visit 4B.

Subjects evaluated ocular itching at 3, 5, and 7 minutes post CAC.Ocular itching was assessed by the subject using the scale anddescriptors using the standard 0-4 scale. The investigator evaluatedconjunctival redness at 7, 15, and 20 minutes post CAC. Conjunctivalredness was assessed by the standard 0-4 scale

Severity scales for both measures were based on a 5-point (9-step) scalewith half-unit (1-step) increments allowed. The average score of botheyes from each subject was the value used for further comparisons amongthe combination ophthalmic suspension, the 2 components individually,and the vehicle control.

Secondary Efficacy Measurements

All secondary efficacy measures were evaluated at Visit 3, Visit 4A andVisit 4B.

-   -   Ciliary redness and episcleral redness were evaluated by the        investigator at 7, 15, and 20 minutes post-CAC using a 5-point        (9-step) scale.    -   Chemosis was evaluated by the investigator at 7, 15 and 20        minutes post-CAC using a 5-point (9-step) scale.    -   Lid swelling was evaluated by the subject at 7, 15, and 20        minutes post-CAC using a 4-point (0-3) scale.    -   Tearing/watery eyes was evaluated by the subject at 7, 15, and        20 minutes post-CAC using a 5-point (0-4) scale.    -   Rhinorrhea (rhinorrhea, nasal pruritis, ear or palate pruritis,        and nasal congestion) was evaluated by the subject at 7, 15, and        20 minutes post-CAC using a 5-point (0-4) scale.    -   Nasal pruritis was evaluated by the subject at 7, 15, and 20        minutes post-CAC using a 5-point (0-4) scale.    -   Ear or palate pruritis was evaluated by the subject at 7, 15,        and 20 minutes post-CAC using a 5-point (0-4) scale.    -   Nasal congestion was evaluated by the subject at 7, 15, and 20        minutes post-CAC using a 5-point (0-4) scale.        Diary scores (daily morning and evening assessments performed by        the subject): (0-4 scale for all)

Ocular

-   -   ocular itching    -   ocular redness    -   eyelid swelling    -   tearing/watery eyes

Nasal

-   -   nasal itching    -   nasal congestion    -   runny nose    -   ear/palate itching

Safety Measurements

The safety measurements were:

-   -   Visual Acuity: Visual acuity (best corrected if necessary) was        measured using an ETDRS chart. Visual acuity was evaluated at        the beginning of each study visit (i.e. prior to slit lamp        examination). At Visit 4B, in addition to the baseline visual        acuity measurement, an additional measurement was performed        post-CAC as part of the safety exit evaluation.    -   Slit lamp biomicroscopy: Slit-lamp biomicroscopy was used to        examine the lids, conjunctiva, cornea, lens, and anterior        chamber. Examinations were conducted at the beginning of each        study visit. At Visit 4B, in addition to the baseline slit lamp        examination, an additional examination was performed post-CAC as        part of the safety exit evaluation.    -   Tolerability Measures: All subjects were asked to complete a        2-part Drop Assessment Questionnaire.        -   Subject Reported Drop Comfort: Subjects were asked to rate            the comfort of the drop in each eye upon instillation, at 1            minute, and at 2 minutes after instillation of study            medication. The assessment used a 10-point scale with 0 as            very comfortable and 10 as very uncomfortable.        -   Description of Drop Comfort: Subjects were asked to choose 3            words (from a list of 12) that described how each drop felt            in the eye. The assessment was performed for each eye at 3            minutes after instillation of study medication. Subjects            were also able to write their own descriptor if they chose            to do so.    -   Dilated Ophthalmoscopy: Dilated ophthalmoscopy was used to        examine the vitreous, retina, macula, choroid and optic nerve.        Examinations were conducted post-CAC at Visit 1 and post-CAC at        Visit 4B as part of the safety exit examination.    -   Intraocular Pressure: IOP was measured using applanation        tonometry with a Goldmann tonometer according to the        manufacturer's instructions. IOP measurements were performed        post-CAC at Visit 1 and post-CAC at Visit 4B as part of the        safety exit examination.    -   Pregnancy Test: A pregnancy test was performed on all females of        childbearing potential at Visit 1, prior to enrollment and        instillation of study drug, and pre-CAC at Visit 4B.    -   Digital Photographs: Digital photographs were taken of both eyes        at Visit 4B pre- and post-CAC.    -   Adverse Events: All adverse events, regardless of relationship        to the study drug, were monitored and reported throughout the        entire course of the study. Adverse events were to be recorded        on the source document and, when applicable, on the adverse        event form of the case report form.

Statistical Methods

Hierarchical statistical hypothesis testing was performed at asignificance level of 0.05 to control type I error in the case that onlyone endpoint was significant. The primary efficacy variables werecompared between Combo treated eyes and Vehicle treated eyes in thefollowing order: 1) There is difference in ocular itching between Comboand Vehicle treated eyes. 2) There is difference in conjunctival rednessbetween Combo and Vehicle treated eyes.

All hypotheses testing were two-sided and performed at type I error (a)of 0.05. Specific statistical tests are described below.

Analysis Populations: The Intent-to-Treat (ITT) population consisted ofsubjects who were randomized. All data was included and no subjects wereexcluded because of protocol violations. The ITT population was analyzedas randomized and was used for efficacy analyses. Missing data wasimputed using LOCF for this population. For sensitivity analysis, MarkovChain Monte Carlo (MCMC) imputation was also applied.

The Per Protocol (PP) was a subset of the ITT population and consistedof subjects who completed all four visits with no major protocolviolations. This population was analyzed as treated using observed dataonly and was used for confirmatory analyses.

The Safety population included all randomized subjects who received atleast one dose of any investigational treatment. The Safety populationwas analyzed as treated and was used for safety analyses; no dataexclusion was allowed for any reason.

Demographic Data: The demographic data was summarized for each treatmentgroup and for overall subjects. Medical history was summarizedseparately for ocular and non-ocular data for each treatment group. Allbaseline characteristic data was summarized using ITT population.Primary Efficacy Variables: For the primary efficacy variables,descriptive statistics, such as, number of subjects, mean, standarddeviation, minimum, maximum, and median for the primary efficacyvariables were summarized by visit, time point and treatment group. Inorder to demonstrate efficacy, for all post-CAC assessments using ITTpopulation with LOCF, the mean difference of ocular itching andconjunctival redness scores between the Combo treated eyes and Vehicletreated eyes were compared using a parametric two-sample t-test, at atwo-sided significance level of 0.05. The non-parametric Wilcoxon ranksum test and an analysis of covariance (ANCOVA) model with treatmenteffects accounting for repeated measurements with baseline adjustmentwere performed as supportive analyses. Assessments measured at Visit 3pre-CAC were used as baseline in the ANCOVA model. Least Square Means(LS Means) for each treatment, the corresponding 95% confidenceintervals, and the estimated treatment difference between the Combotreated eyes and Vehicle treated eyes were calculated from this ANCOVAmodel. For sensitivity analysis, the ITT population was analyzed withMarkov Chain Monte Carlo (MCMC) imputation implemented using the MIprocedure within SAS®. A supportive analysis was also performed on theper protocol population with observed data only. The mean differencebetween the Combo treated eyes and its individual component treated eyeswas analyzed in a similar manner.Secondary Efficacy Variables: For the secondary efficacy variables,analyses were performed in a manner similar to primary endpoints, forboth the ITT population with observed data only and the per protocolpopulation.Diary Data: Diary data was analyzed to assess any environmentaltreatment effect. The score of each ocular symptom and nasal symptom wassummarized using descriptive statistics (number of subjects, mean,standard deviation, minimum, maximum, and median) by assessment time,day, and treatment. The mean difference between Combo treated eyes andVehicle treated eyes was tested using a two-sample t-test and thenon-parametric Wilcoxon rank sum test at a significance level of 0.05.For a given symptom, Combo treated eyes must have had statisticallysignificantly lower mean symptom severity scores on the majority of days(7 out of 12 days) compared to Vehicle treated eyes in order to claimsuperiority. The mean difference between the Combo treated eyes and itsindividual component treated eyes were analyzed in a similar manner.In addition, an analysis of covariance (ANCOVA) was applied to analyzethe overall diary mean scores (Day 1-Day 12). Treatment effect, diaryday, and pollen count by site were considered as covariates in the modelwith adjustment for repeated measurements within subject. Least SquareMeans (LS Means) for each treatment, the corresponding 95% confidenceintervals, and the estimated treatment difference between test articleand control were calculated from this ANCOVA model. All analyses ofdiary data were conducted on the ITT population with observed data only.In addition, the same statistical analyses were conducted on the perprotocol population.Safety Analyses: All safety analyses were performed on the safetypopulation. Descriptive statistics (number of observations, mean,median, standard deviation, minimum, and maximum) were provided forvisual acuity and intraocular pressure. Frequencies and percentages wereprovided for categorical variables in slit lamp biomicroscopy anddilated ophthalmoscopy.Adverse events were coded to a system organ class and preferred termusing the Medical Dictionary for Regulatory Activities, version 12.1(MedDRA). Frequencies and percentages were provided per treatment groupfor treatment-emergent adverse events (TEAEs), serious TEAEs, and TEAEcausing premature discontinuation. An adverse event was treatmentemergent if it occurred or worsened after the first dose of studytreatment up through Day 14. All adverse events were assigned a severitygrade of mild, moderate, or severe. Furthermore, frequencies were givenfor subjects with TEAEs by: system organ class; system organ class andpreferred term; system organ class, preferred term and maximal severity;system organ class, preferred term and strongest relationship. AEs wereclassified as either being related to treatment or not related. AEsrelated to treatment were to include AEs classified as definite,probable, possible or unknown. AEs classified as not related or unlikelywere considered unrelated.Tolerability Variables: The tolerability variables were analyzed for theITT population. Drop comfort was summarized using mean, median, standarddeviation, minimum and maximum and was analyzed using a two-samplet-test to compare Combo group to its components and Vehicle groups. Dropdescriptor assessment were summarized using counts and percentages andwere analyzed using Fisher's exact test or Chi-Square as appropriate tocompare Combo group to its components and Vehicle groups.

Efficacy Results

All efficacy analyses were performed on data collected at Visits 3, 4A,and 4B. Primary and secondary efficacy analyses were performed on boththe ITT population and the PP population.

ITT population: Eighty three (83) subjects were randomized at Visit 2Band comprised the ITT population. No subjects were excluded from the ITTpopulation because of protocol violations. The ITT population wasanalyzed as randomized; all data were included. Missing data wereimputed using the last observation carried forward method (LOCF) for theITT population.PP Population: The PP population was a subset of the ITT population andconsisted of subjects who completed all four visits with no majorprotocol violations. This population was analyzed as treated usingobserved data only and was used for confirmatory analyses. Fourteen (14)subjects in the ITT population were excluded from the PP population; 12of these subjects did not complete the study.All safety analyses were performed on the safety population.Safety population: The Safety population included all randomizedsubjects who received at least one dose of any investigationaltreatment. All 83 subjects randomized at Visit 2B also received theirfirst dose of assigned study medication post CAC at Visit 2B, and thuscomprise the Safety population. The Safety population was analyzed astreated; no data exclusion was allowed for any reason.

Criteria for Effectiveness

The study design allowed the evaluation of three aspects of the allergicreaction.Early Allergic Reaction: Onset of Action (Visit 3, CAC administered 15min after Visit 3 dose)Early Allergic Reaction: Duration of Action (Visit 4A, CAC administered16 hours after Visit 3 dose, Visit 4 dose given 30 min after the CAC)Late Inflammatory Reaction: (Visit 4B, no dose at Visit 4B, CACadministered 8 hours after Visit 4A dose)

The primary clinical efficacy evaluation of this study was thedetermination of superiority of cetirizine 0.1%/fluticasone 0.005%ophthalmic suspension (Combo) over the Vehicle. A mean difference of 1.0unit was considered clinically significant at a single time point. Inorder to demonstrate efficacy at a single visit, Combo-treated eyes musthave shown statistical and clinical superiority over Vehicle-treatedeyes by at least 0.5 units on a 5-point scale at all post-CAC timepoints and at least 1 unit at a majority (i.e., 2 out of 3) of post-CACtime points. At each post-CAC time point, a treatment difference wasconsidered statistically significant if it was significant at atwo-sided significance level of 0.05.

Primary Efficacy Endpoints

The primary efficacy measures were ocular itching (at 3, 5, and 7minutes post-CAC) and conjunctival redness (at 7, 15, and 20 minutespost-CAC).Table 14 presents an overview of the Active treatments (Combo,cetirizine 0.1%, fluticasone 0.005%) vs Vehicle data for the primary andsecondary CAC data. The shadings in the individual cells represent theendpoints for which the comparisons of Active treatment to Vehicle wereclinically significant, statistically significant-only, or trendingtowards statistical significance (0.05<P<0.10). The numbers within thecells represent the treatment difference from the ANCOVA model (LS meanActive minus LS mean Vehicle).Table 15 thru 26 present the details of the comparisons between Comboand the active components, as well as between Combo and Vehicle, forocular itching and for conjunctival redness in both the ITT with LOCFpopulation and the PP population at study Visits 3, 4A, and 4B.

-   -   Combo demonstrated clinical efficacy in the prevention of ocular        itching. The mean itching scores for Combo were significantly        lower (P<0.05) than vehicle at all 3 time points at all 3 visits        (Visits 3, 4A and 4B). The treatment differences (Combo mean        minus Vehicle mean) were greater than 1 unit at all 3 time        points at all 3 visits. See Tables 14-20 for the detailed ocular        itching data in the ITT with LOCF population and the PP        populations at Visits 3, 4A, and 4B.    -   Combo demonstrated statistical superiority over vehicle in the        prevention of conjunctival redness. The mean conjunctival        redness scores for Combo were significantly lower (P<0.05) than        vehicle at all 3 time points at all 3 visits. The magnitude of        the treatment differences (Combo mean minus Vehicle mean) was        greater than 0.5 units, but less than 1 unit, for all 3 time        points at Visits 3 and 4B, and for 2 of the 3 time points at        Visit 4A. See Tables 21-26 for the detailed conjunctival redness        data in the ITT with LOCF population and the PP populations at        Visits 3, 4A, and 4B.    -   Combo demonstrated statistical superiority over cetirizine in        the prevention of conjunctival redness at all 3 time points of        Visit 4B (PP population). See Table 26 for the detailed        conjunctival redness data in the PP population at Visit 4B.    -   Combo demonstrated statistically superiority over fluticasone in        the prevention of ocular itching (Visit 3 and Visit 4B) and in        the prevention of conjunctival redness (Visit 3 and Visit 4B).        See Tables 15, 16, 19, and 20 for the details of the ocular        itching data. See Tables 21, 22, 25, and 26 for the details of        the conjunctival redness data.

Secondary Efficacy Endpoints (CAC Data)

Results for all of the secondary efficacy assessments at the Visit 3,Visit 4A, and Visit 4B CAC studies are summarized in Table 25.

-   -   Combo demonstrated clinical efficacy in the prevention of lid        swelling. The mean lid swelling scores for Combo were        significantly lower (P<0.05) than vehicle at all 3 time points        at all 3 visits (Visits 3, 4A and 4B). The treatment differences        (Combo mean minus Vehicle mean) were greater than 0.5 unit at        all 3 time points at all 3 visits, and greater than 1.0 unit for        at least 2 out of 3 time points at all 3 visits. See Tables        29-31 for the detailed lid swelling data in the PP population at        Visits 3, 4A, and 4B, respectively.

TABLE 14 Overview of CAC data

Numbers within cells represents the treatment differences calculatedwith the ANCOVA model (LS mean active minus LS mean Vehicle).

TABLE 15 Ocular Itching, Visit 3, 15-min Onset of Action, ITT Populationwith LOCF Group 1.1.1.1.2 Cetirizine Fluticasone 1.1.1.1.3 Vehicle1.1.1.1.1 Combo 0.1% 0.005% 1.1.1.1.4 Time Point (N = 21) (N = 21) (N =20) (N = 21) Pre-CAC N 20 20 19 19 mean (SD) 0.06 (0.228) 0.20 (0.616)0.11 (0.459) 0.13 (0.403) 3 min post-CAC N 20 19 18 18 mean (SD) 1.33(0.974) 0.99 (0.752) 2.11 (1.173) 2.90 (0.967) P value¹ — 0.2315 0.0324<0.0001 P value² — 0.3486 0.0487 0.0001 5 min post CAC N 20 19 18 18mean (SD) 1.44 (1.076) 1.33 (0.590) 2.25 (1.057) 3.11 (0.944) P value¹ —0.6968 0.0246 <0.0001 P value² — 0.9662 0.0272 0.0001 7 min post-CAC N20 19 18 18 mean (SD) 1.31 (1.066) 1.59 (0.894) 2.03 (1.131) 2.97(1.018) P value¹ — 0.3800 0.0533 <0.0001 P value² — 0.4535 0.0935 0.0001ANCOVA LS mean    1.33 1.29 2.09 2.95 95% CI (0.92, 1.75) (0.86, 1.71)(1.65, 2.52) (2.52, 3.38) TRT difference³ — −0.05 −0.75 −1.62 P value⁴ —0.8719 0.0748 <0.0001 ¹P value calculated using a two-sample t-test tocompare Combo to Vehicle and to the individual components. ²P valuecalculated using a Wilcoxon rank sum test to compare Combo to Vehicleand to the individual components. ³TRT difference: difference in the LSmeans (Combo LS mean − vehicle LS mean or component LS mean). ⁴P valuefrom the ANCOVA analysis, with treatment and baseline score (Visit 3pre-CAC) as covariates, comparing Combo to vehicle and to its individualcomponents.

TABLE 16 Ocular Itching, Visit 3, 15-min Onset of Action, PP PopulationGroup 1.1.1.1.6 Cetirizine Fluticasone 1.1.1.1.7 Vehicle 1.1.1.1.5 Combo0.1% 0.005% 1.1.1.1.8 Time Point (N = 21) (N = 21) (N = 20) (N = 21)Pre-CAC N 18 17 17 17 mean (SD) 0.07 (0.240) 0.24 (0.664) 0.12 (0.485)0.15 (0.424) 3 min post-CAC N 18 17 17 17 mean (SD) 1.19 (0.922) 1.00(0.795) 2.24 (1.081) 2.93 (0.991) TRT difference P value¹ — 0.50810.0045 <0.0001 P value² — 0.6520 0.0087 0.0001 5 min post CAC N 18 17 1717 mean (SD) 1.29 (1.030) 1.31 (0.616) 2.35 (0.992) 3.12 (0.973) Pvalue¹ — 0.9524 0.0039 <0.0001 P value² — 0.6654 0.0045 0.0001 7 minpost-CAC N 18 17 17 17 mean (SD) 1.18 (1.042) 1.54 (0.936) 2.12 (1.097)2.97 (1.049) P value¹ — 0.2851 0.0143 <0.0001 P value² — 0.2805 0.02190.0001 ANCOVA LS mean    1.20 1.27 2.19 2.96 95% CI (0.77, 1.63) (0.82,1.71) (1.75, 2.63) (2.52, 3.40) TRT difference³ — −0.06 −0.99 −1.76 Pvalue⁴ — 0.8719 0.0020 <0.0001 ¹P value calculated using a two-samplet-test to compare Combo to Vehicle and to the individual components. ²Pvalue calculated using a Wilcoxon rank sum test to compare Combo toVehicle and to the individual components. ³TRT difference: difference inthe LS means (Combo LS mean − vehicle LS mean or component LS mean). ⁴Pvalue from the ANCOVA analysis, with treatment and baseline score (Visit3 pre-CAC) as covariates, comparing Combo to vehicle and to itsindividual components.

TABLE 17 Ocular Itching, Visit 4A, 16-hr Duration of Action, ITTPopulation with LOCF Group 1.1.1.1.10 Cetirizine Fluticasone 1.1.1.1.11Vehicle 1.1.1.1.9 Combo 0.1% 0.005% 1.1.1.1.12 Time Point (N = 21) (N =21) (N = 20) (N = 21) Pre-CAC N 20 20 19 19 mean (SD) 0.06 (0.228) 0.38(0.651) 0.12 (0.357) 0.41 (0.535) 3 min post-CAC N 20 19 18 18 mean (SD)1.75 (1.112) 1.92 (1.131) 1.88 (1.082) 3.04 (0.693) P value¹ — 0.63690.7277 0.0001 P value² — 0.6402 0.7131 0.0006 5 min post CAC N 20 19 1818 mean (SD) 1.95 (1.160) 2.24 (0.991) 2.21 (1.132) 3.18 (0.706) Pvalue¹ — 0.4111 0.4920 0.0004 P value² — 0.4889 0.6178 0.0015 7 minpost-CAC N 20 19 18 18 mean (SD) 1.98 (1.067) 2.12 (1.156) 2.11 (1.231)3.18 (0.727) P value¹ — 0.6899 0.7194 0.0002 P value² — 0.8655 0.88310.0005 ANCOVA LS mean    1.87 2.03 2.00 3.11 95% CI (1.42, 2.31) (1.57,2.49) (1.54, 2.47) (2.65, 3.58) TRT difference³ — −0.16 −0.14 −1.25 Pvalue⁴ — 0.6156 0.6746 0.0003 ¹P value calculated using a two-samplet-test to compare Combo to Vehicle and to the individual components. ²Pvalue calculated using a Wilcoxon rank sum test to compare Combo toVehicle and to the individual components. ³TRT difference: difference inthe LS means (Combo LS mean − vehicle LS mean or component LS mean). ⁴Pvalue from the ANCOVA analysis, with treatment and baseline score (Visit4A pre-CAC) as covariates, comparing Combo to vehicle and to itsindividual components.

TABLE 18 Ocular Itching, Visit 4A, 16-hr Duration of Action, PPPopulation Group 1.1.1.1.14 Cetirizine Fluticasone 1.1.1.1.15 Vehicle1.1.1.1.13 Combo 0.1% 0.005% 1.1.1.1.16 Time Point (N = 21) (N = 21) (N= 20) (N = 21) Pre-CAC N 18 17 17 17 mean (SD) 0.07 (0.240) 0.34 (0.679)0.13 (0.376) 0.46 (0.547) 3 min post-CAC N 18 17 17 17 mean (SD) 1.61(1.085) 1.96 (1.187) 1.90 (1.111) 3.04 (0.714) P value¹ — 0.3772 0.44710.0001 P value² — 0.3340 0.3876 0.0004 5 min post CAC N 18 17 17 17 mean(SD) 1.81 (1.130) 2.26 (1.033) 2.22 (1.166) 3.16 (0.723) P value¹ —0.2179 0.2930 0.0002 P value² — 0.2457 0.3451 0.0009 7 min post-CAC N 1816 17 17 mean (SD) 1.86 (1.051) 2.14 (1.255) 2.07 (1.259) 3.16 (0.744) Pvalue¹ — 0.4899 0.5928 0.0002 P value² — 0.5673 0.8032 0.0004 ANCOVA LSmean    1.74 2.07 2.00 3.11 95% CI (1.26, 2.22) (1.57, 2.56) (1.51,2.49) (2.61, 3.60) TRT difference³ — −0.33 −0.26 −1.37 P value⁴ — 0.35070.4576 0.0002 ¹P value calculated using a two-sample t-test to compareCombo to Vehicle and to the individual components. ²P value calculatedusing a Wilcoxon rank sum test to compare Combo to Vehicle and to theindividual components. ³TRT difference: difference in the LS means(Combo LS mean − vehicle LS mean or component LS mean). ⁴P value fromthe ANCOVA analysis, with treatment and baseline score (Visit 3 pre-CAC)as covariates, comparing Combo to vehicle and to its individualcomponents. Source Table 14.2.1.3

TABLE 19 Ocular Itching, Visit 4B, 8-hour Rechallenge, ITT Populationwith LOCF Group 1.1.1.1.18 Cetirizine Fluticasone 1.1.1.1.19 Vehicle1.1.1.1.17 Combo 0.1% 0.005% 1.1.1.1.20 Time Point (N = 21) (N = 21) (N= 20) (N = 21) Pre-CAC N 20 20 19 19 mean (SD) 0.08 (0.245) 0.38 (0.631)0.11 (0.254) 0.28 (0.463) 3 min post-CAC N 20 19 18 18 mean (SD) 1.43(1.007) 1.53 (0.916) 2.01 (0.872) 2.99 (0.627) P value¹ — 0.7441 0.0613<0.0001 P value² — 0.7344 0.0615 <0.0001 5 min post CAC N 20 19 18 18mean (SD) 1.56 (1.022) 1.83 (0.954) 2.17 (0.899) 2.90 (0.703) P value¹ —0.4503 0.0605 <0.0001 P value² — 0.5061 0.0905 0.0001 7 min post-CAC N20 19 18 18 mean (SD) 1.64 (1.071) 1.86 (0.925) 2.03 (0.935) 2.79(0.792) P value¹ — 0.5006 0.2384 0.0006 P value² — 0.7342 0.3843 0.0010ANCOVA LS mean    1.53 1.70 2.03 2.89 95% CI (1.15, 1.92) (1.30, 2.10)(1.62, 2.43) (2.49, 3.29) TRT difference³ — −0.17 −0.50 −1.36 P value⁴ —0.5500 0.0804 <0.0001 ¹P value calculated using a two-sample t-test tocompare Combo to Vehicle and to the individual components. ²P valuecalculated using a Wilcoxon rank sum test to compare Combo to Vehicleand to the individual components. ³TRT difference: difference in the LSmeans (Combo LS mean − vehicle LS mean or component LS mean). ⁴P valuefrom the ANCOVA analysis, with treatment and baseline score (Visit 4Apre-CAC) as covariates, comparing Combo to vehicle and to its individualcomponents. Source Table 14.2.1.1

TABLE 20 Ocular Itching, Visit 4B, 8-hour Rechallenge, PP PopulationGroup 1.1.1.1.22 Cetirizine Fluticasone 1.1.1.1.23 Vehicle 1.1.1.1.21Combo 0.1% 0.005% 1.1.1.1.24 Time Point (N = 21) (N = 21) (N = 20) (N =21) Pre-CAC N 18 17 17 17 mean (SD) 0.08 (0.257) 0.34 (0.655) 0.12(0.267) 0.31 (0.480) 3 min post-CAC N 18 17 17 17 mean (SD) 1.22 (0.831)1.50 (0.964) 2.04 (0.889) 2.99 (0.646) P value¹ — 0.3694 0.0081 <0.0001P value² — 0.4647 0.0104 <0.0001 5 min post CAC N 18 17 17 17 mean (SD)1.40 (0.948) 1.81 (0.994) 2.18 (0.926) 2.87 (0.708) P value¹ — 0.22550.0201 <0.0001 P value² — 0.3028 0.0272 0.0001 7 min post-CAC N 18 17 1717 mean (SD) 1.54 (1.089) 1.85 (0.956) 1.99 (0.946) 2.75 (0.795) Pvalue¹ — 0.3748 0.2065 0.0007 P value² — 0.5611 0.3427 0.0015 ANCOVA LSmean    1.38 1.68 2.02 2.87 95% CI (0.98, 1.79) (1.27, 2.10) (1.61,2.44) (2.45, 3.28) TRT difference³ — −0.30 −0.64 −1.48 P value⁴ — 0.30990.0307 <0.0001 ¹P value calculated using a two-sample t-test to compareCombo to Vehicle and to the individual components. ²P value calculatedusing a Wilcoxon rank sum test to compare Combo to Vehicle and to theindividual components. ³TRT difference: difference in the LS means(Combo LS mean − vehicle LS mean or component LS mean). ⁴P value fromthe ANCOVA analysis, with treatment and baseline score (Visit 3 pre-CAC)as covariates, comparing Combo to vehicle and to its individualcomponents. Source Table 14.2.1.3

TABLE 21 Conjunctival Redness, Visit 3, 15-min Onset of Action, ITTPopulation with LOCF Group 1.1.1.1.26 Cetirizine Fluticasone 1.1.1.1.27Vehicle 1.1.1.1.25 Combo 0.1% 0.005% 1.1.1.1.28 Time Point (N = 21) (N =21) (N = 20) (N = 21) Pre-CAC N 20 20 19 19 mean (SD) 0.74 (0.286) 0.93(0.514) 0.84 (0.410) 0.88 (0.403) 7 min post-CAC N 20 19 18 18 mean (SD)1.70 (0.677) 1.97 (0.812) 2.18 (0.835) 2.49 (0.639) P value¹ — 0.26180.0615 0.0008 P value² — 0.2700 0.0450 0.0010 15 min post CAC N 20 19 1818 mean (SD) 2.04 (0.704) 2.25 (0.997) 2.44 (0.770) 2.58 (0.733) Pvalue¹ — 0.4494 0.0991 0.0253 P value² — 0.5249 0.1048 0.0207 20 minpost-CAC N 20 19 18 18 mean (SD) 2.04 (0.745) 2.37 (0.980) 2.51 (0.838)2.58 (0.733) P value¹ — 0.2453 0.0738 0.0290 P value² — 0.1796 0.05940.0182 ANCOVA LS mean    1.97 2.10 2.36 2.51 95% CI (1.67, 2.27) (1.79,2.41) (2.04, 2.67) (2.19, 2.82) TRT difference³ — −0.13 −0.39 −0.53 Pvalue⁴ — 0.5520 0.0806 0.0174 ¹P value calculated using a two-samplet-test to compare Combo to Vehicle and to the individual components. ²Pvalue calculated using a Wilcoxon rank sum test to compare Combo toVehicle and to the individual components. ³TRT difference: difference inthe LS means (Combo LS mean − vehicle LS mean or component LS mean). ⁴Pvalue from the ANCOVA analysis, with treatment and baseline score (Visit4A pre-CAC) as covariates, comparing Combo to vehicle and to itsindividual components. Source Table 14.2.2.1

TABLE 22 Conjunctival Redness, Visit 3, 15-min Onset of Action, PPPopulation Group 1.1.1.1.30 Cetirizine Fluticasone 1.1.1.1.31 Vehicle1.1.1.1.29 Combo 0.1% 0.005% 1.1.1.1.32 Time Point (N = 21) (N = 21) (N= 20) (N = 21) Pre-CAC N 18 17 17 17 mean (SD) 0.75 (0.297) 0.99 (0.519)0.85 (0.424) 0.90 (0.415) 7 min post-CAC N 18 17 17 17 mean (SD) 1.65(0.697) 2.09 (0.760) 2.28 (0.744) 2.50 (0.656) P value¹ — 0.0873 0.01510.0008 P value² — 0.0841 0.0157 0.0013 15 min post CAC N 18 17 17 17mean (SD) 1.97 (0.712) 2.38 (0.944) 2.50 (0.755) 2.62 (0.740) P value¹ —0.1590 0.0413 0.0130 P value² — 0.1896 0.0330 0.0082 20 min post-CAC N18 17 17 17 mean (SD) 1.97 (0.757) 2.50 (0.914) 2.53 (0.861) 2.62(0.740) P value¹ — 0.0732 0.0509 0.0156 P value² — 0.0428 0.0347 0.0088ANCOVA LS mean    1.92 2.20 2.42 2.54 95% CI (1.60, 2.24) (1.88, 2.53)(2.10, 2.75) (2.22, 2.86) TRT difference³ — −0.28 −0.50 −0.62 P value⁴ —0.2254 0.0298 0.0083 ¹P value calculated using a two-sample t-test tocompare Combo to Vehicle and to the individual components. ²P valuecalculated using a Wilcoxon rank sum test to compare Combo to Vehicleand to the individual components. ³TRT difference: difference in the LSmeans (Combo LS mean − vehicle LS mean or component LS mean). ⁴P valuefrom the ANCOVA analysis, with treatment and baseline score (Visit 3pre-CAC) as covariates, comparing Combo to vehicle and to its individualcomponents. Source Table 14.2.2.3

TABLE 23 Conjunctival Redness, Visit 4A, 16-hr Duration of Action, ITTPopulation with LOCF Group 1.1.1.1.34 Cetirizine Fluticasone 1.1.1.1.35Vehicle 1.1.1.1.33 Combo 0.1% 0.005% 1.1.1.1.36 Time Point (N = 21) (N =21) (N = 20) (N = 21) Pre-CAC N 20 20 19 19 mean (SD) 0.84 (0.327) 0.93(0.354) 0.91 (0.303) 1.03 (0.343) 7 min post-CAC N 20 19 18 18 mean (SD)1.56 (0.451) 1.78 (0.478) 1.83 (0.485) 2.01 (0.348) P value¹ — 0.15960.0843 0.0014 P value² — 0.1326 0.0627 0.0023 15 min post CAC N 20 19 1818 mean (SD) 1.68 (0.507) 1.84 (0.410) 1.97 (0.484) 2.15 (0.322) Pvalue¹ — 0.2642 0.0730 0.0014 P value² — 0.2680 0.0542 0.0024 20 minpost-CAC N 20 19 18 18 mean (SD) 1.66 (0.424) 1.88 (0.567) 1.81 (0.511)2.04 (0.386) P value¹ — 0.1827 0.3574 0.0065 P value² — 0.0793 0.22510.0053 ANCOVA LS mean    1.63 1.82 1.83 2.03 95% CI (1.45, 1.82) (1.63,2.01) (1.64, 2.03) (1.84, 2.23) TRT difference³ — −0.19 −0.20 −0.40 Pvalue⁴ — 0.1742 0.1441 0.0045 ¹P value calculated using a two-samplet-test to compare Combo to Vehicle and to the individual components. ²Pvalue calculated using a Wilcoxon rank sum test to compare Combo toVehicle and to the individual components. ³TRT difference: difference inthe LS means (Combo LS mean − vehicle LS mean or component LS mean). ⁴Pvalue from the ANCOVA analysis, with treatment and baseline score (Visit4A pre-CAC) as covariates, comparing Combo to vehicle and to itsindividual components. Source Table 14.2.2.1

TABLE 24 Conjunctival Redness, Visit 4A, 16-hr Duration of Action, PPPopulation Group 1.1.1.1.38 Cetirizine Fluticasone 1.1.1.1.39 Vehicle1.1.1.1.37 Combo 0.1% 0.005% 1.1.1.1.40 Time Point (N = 21) (N = 21) (N= 20) (N = 21) Pre-CAC N 18 17 17 17 mean (SD) 0.83 (0.343) 0.93 (0.383)0.90 (0.319) 1.01 (0.359) 7 min post-CAC N 18 17 17 17 mean (SD) 1.50(0.429) 1.82 (0.482) 1.81 (0.488) 2.00 (0.354) P value¹ — 0.0443 0.05600.0007 P value² — 0.0263 0.0385 0.0009 15 min post CAC N 18 17 17 17mean (SD) 1.61 (0.487) 1.90 (0.396) 1.94 (0.504) 2.15 (0.331) P value¹ —0.0649 0.0575 0.0006 P value² — 0.0581 0.0413 0.0011 20 min post-CAC N18 17 17 17 mean (SD) 1.60 (0.385) 1.97 (0.514) 1.79 (0.525) 2.03(0.394) P value¹ — 0.0219 0.2176 0.0025 P value² — 0.0079 0.1283 0.0025ANCOVA LS mean    1.57 1.88 1.82 2.02 95% CI (1.38, 1.76) (1.69, 2.08)(1.62, 2.01) (1.83, 2.22) TRT difference³ — −0.32 −0.25 −0.46 P value⁴ —0.0278 0.0765 0.0016 ¹P value calculated using a two-sample t-test tocompare Combo to Vehicle and to the individual components. ²P valuecalculated using a Wilcoxon rank sum test to compare Combo to Vehicleand to the individual components. ³TRT difference: difference in the LSmeans (Combo LS mean − vehicle LS mean or component LS mean). ⁴P valuefrom the ANCOVA analysis, with treatment and baseline score (Visit 3pre-CAC) as covariates, comparing Combo to vehicle and to its individualcomponents. Source Table 14.2.2.3

TABLE 25 Conjunctival Redness, Visit 4B, 8-hour Rechallenge, ITTPopulation with LOCF Group 1.1.1.1.42 Cetirizine Fluticasone 1.1.1.1.43Vehicle 1.1.1.1.41 Combo 0.1% 0.005% 1.1.1.1.44 Time Point (N = 21) (N =21) (N = 20) (N = 21) Pre-CAC N 20 20 19 19 mean (SD) 0.71 (0.424) 0.96(0.454) 0.88 (0.268) 1.21 (0.292) 7 min post-CAC N 20 19 18 18 mean (SD)1.39 (0.610) 1.66 (0.560) 1.81 (0.442) 1.96 (0.346) P value¹ — 0.15740.0201 0.0011 P value² — 0.1493 0.0299 0.0042 15 min post CAC N 20 19 1818 mean (SD) 1.39 (0.626) 1.70 (0.518) 1.85 (0.557) 2.14 (0.366) Pvalue¹ — 0.0998 0.0218 0.0001 P value² — 0.0924 0.0264 0.0004 20 minpost-CAC N 20 19 18 18 mean (SD) 1.44 (0.617) 1.70 (0.581) 1.81 (0.546)2.14 (0.395) P value¹ — 0.1837 0.0589 0.0002 P value² — 0.1524 0.05140.0006 ANCOVA LS mean    1.44 1.66 1.81 2.04 95% CI (1.21, 1.66) (1.43,1.89) (1.58, 2.04) (1.81, 2.28) TRT difference³ — −0.22 −0.37 −0.61 Pvalue⁴ — 0.1659 0.0230 0.0003 ¹P value calculated using a two-samplet-test to compare Combo to Vehicle and to the individual components. ²Pvalue calculated using a Wilcoxon rank sum test to compare Combo toVehicle and to the individual components. ³TRT difference: difference inthe LS means (Combo LS mean − vehicle LS mean or component LS mean). ⁴Pvalue from the ANCOVA analysis, with treatment and baseline score (Visit4A pre-CAC) as covariates, comparing Combo to vehicle and to itsindividual components. Source Table 14.2.2.1

TABLE 26 Conjunctival Redness, Visit 4B, 8-hr Rechallenge, PP PopulationGroup 1.1.1.1.46 Cetirizine Fluticasone 1.1.1.1.47 Vehicle 1.1.1.1.45Combo 0.1% 0.005% 1.1.1.1.48 Time Point (N = 21) (N = 21) (N = 20) (N =21) Pre-CAC N 18 17 17 17 mean (SD) 0.69 (0.442) 0.99 (0.488) 0.87(0.281) 1.22 (0.305) 7 min post-CAC N 18 17 17 17 mean (SD) 1.31 (0.585)1.72 (0.558) 1.78 (0.441) 1.94 (0.348) P value¹ — 0.0392 0.0107 0.0005 Pvalue² — 0.0376 0.0128 0.0013 15 min post CAC N 18 17 17 17 mean (SD)1.29 (0.577) 1.76 (0.504) 1.82 (0.564) 2.13 (0.376) P value¹ — 0.01430.0094 <0.0001 P value² — 0.0144 0.0116 0.0001 20 min post-CAC N 18 1717 17 mean (SD) 1.35 (0.576) 1.78 (0.551) 1.79 (0.561) 2.13 (0.406) Pvalue¹ — 0.0300 0.0263 0.0001 P value² — 0.0230 0.0229 0.0002 ANCOVA LSmean    1.35 1.73 1.79 2.04 95% CI (1.12, 1.58) (1.49, 1.96) (1.56,2.03) (1.80, 2.27) TRT difference³ — −0.37 −0.44 −0.69 P value⁴ — 0.02720.0086 0.0001 ¹P value calculated using a two-sample t-test to compareCombo to Vehicle and to the individual components. ²P value calculatedusing a Wilcoxon rank sum test to compare Combo to Vehicle and to theindividual components. ³TRT difference: difference in the LS means(Combo LS mean − vehicle LS mean or component LS mean). ⁴P value fromthe ANCOVA analysis, with treatment and baseline score (Visit 3 pre-CAC)as covariates, comparing Combo to vehicle and to its individualcomponents. Source Table 14.2.2.3

TABLE 27 Lid Swelling, Visit 3, 15-min Onset of Action PP PopulationGroup 1.1.1.1.50 Cetirizine Fluticasone 1.1.1.1.51 Vehicle 1.1.1.1.49Combo 0.1% 0.005% 1.1.1.1.52 Time Point (N = 21) (N = 21) (N = 20) (N =21) Pre-CAC N 18 17 17 17 mean (SD) 0.1 (0.24) 0.0 (0.00) 0.1 (0.24) 0.1(0.33) 7 min post-CAC N 18 17 17 17 mean (SD) 0.2 (0.43) 0.5 (0.50) 1.2(0.88) 1.4 (0.63) P value¹ — 0.0879 0.0005 <0.0001 P value² — 0.08170.0006 <0.0001 15 min post CAC N 18 17 17 17 mean (SD) 0.4 (0.61) 0.7(0.75) 1.1 (0.97) 1.5 (0.74) P value¹ — 0.1456 0.0174 <0.0001 P value² —0.1419 0.0178 0.0002 20 min post-CAC N 18 17 17 17 mean (SD) 0.4 (0.62)0.9 (0.75) 1.1 (0.86) 1.5 (0.85) P value¹ — 0.0543 0.0128 0.0002 Pvalue² — 0.0579 0.0145 0.0004 ANCOVA LS mean   0.3 0.7 1.1 1.4 95% CI(0.0, 0.6) (0.4, 1.0) (0.8, 1.5) (1.1, 1.7) TRT difference³ — −0.4 −0.8−1.1 P value⁴ — 0.0916 0.0006 <0.0001 ¹P value calculated using atwo-sample t-test to compare Combo to Vehicle and to the individualcomponents. ²P value calculated using a Wilcoxon rank sum test tocompare Combo to Vehicle and to the individual components. ³TRTdifference: difference in the LS means (Combo LS mean − vehicle LS meanor component LS mean). ⁴P value from the ANCOVA analysis, with treatmentand baseline score (Visit 4A pre-CAC) as covariates, comparing Combo tovehicle and to its individual components. Source Table 14.2.6.2

TABLE 28 Lid Swelling, Visit 4A, 16-hr Duration of Action, PP PopulationGroup 1.1.1.1.54 Cetirizine Fluticasone 1.1.1.1.55 Vehicle 1.1.1.1.53Combo 0.1% 0.005% 1.1.1.1.56 Time Point (N = 21) (N = 21) (N = 20) (N =21) Pre-CAC N 18 17 17 17 mean (SD) 0.3 (0.59) 0.2 (0.35) 0.2 (0.40) 0.5(0.62) 7 min post-CAC N 18 17 17 17 mean (SD) 0.6 (0.51) 1.2 (0.95) 1.1(0.86) 1.5 (0.66) P value¹ — 0.0252 0.0274 0.0001 P value² — 0.03990.0398 0.0002 15 min post CAC N 18 17 17 17 mean (SD) 0.7 (0.59) 1.3(1.00) 1.1 (0.86) 1.6 (0.70) P value¹ — 0.0340 0.0827 0.0001 P value² —0.0548 0.1071 0.0003 20 min post-CAC N 18 17 17 17 mean (SD) 0.7 (0.59)1.3 (0.92) 1.2 (0.95) 1.7 (0.68) P value¹ — 0.0314 0.0564 0.0001 Pvalue² — 0.0396 0.0740 0.0002 ANCOVA LS mean   0.6 1.2 1.2 1.6 95% CI(0.3, 1.0) (0.9, 1.6) (0.8, 1.5) (1.2, 1.9) TRT difference³ — −0.6 −0.5−1.0 P value⁴ — 0.0152 0.0298 0.0002 ¹P value calculated using atwo-sample t-test to compare Combo to Vehicle and to the individualcomponents. ²P value calculated using a Wilcoxon rank sum test tocompare Combo to Vehicle and to the individual components. ³TRTdifference: difference in the LS means (Combo LS mean − vehicle LS meanor component LS mean). ⁴P value from the ANCOVA analysis, with treatmentand baseline score (Visit 4A pre-CAC) as covariates, comparing Combo tovehicle and to its individual components. Source Table 14.2.6.2

TABLE 29 Lid Swelling, Visit 4B, 8-hour Rechallenge, PP Population Group1.1.1.1.58 Cetirizine Fluticasone 1.1.1.1.59 Vehicle 1.1.1.1.57 Combo0.1% 0.005% 1.1.1.1.60 Time Point (N = 21) (N = 21) (N = 20) (N = 21)Pre-CAC N 18 17 17 17 mean (SD) 0.1 (0.32) 0.3 (0.59) 0.2 (0.53) 0.4(0.79) 7 min post-CAC N 18 17 17 17 mean (SD) 0.4 (0.51) 0.7 (0.58) 1.1(1.03) 1.6 (0.93) P value¹ — 0.2216 0.0183 0.0002 P value² — 0.25750.0352 0.0003 15 min post CAC N 18 17 17 17 mean (SD) 0.5 (0.50) 1.0(0.76) 1.1 (1.00) 1.6 (0.70) P value¹ — 0.0306 0.0194 <0.0001 P value² —0.0421 0.0311 0.0001 20 min post-CAC N 18 17 17 17 mean (SD) 0.5 (0.50)1.0 (0.88) 1.0 (0.94) 1.6 (0.66) P value¹ — 0.0407 0.0405 <0.0001 Pvalue² — 0.0635 0.0683 0.0001 ANCOVA LS mean   0.5 0.8 1.1 1.6 95% CI(0.1, 0.8) (0.5, 1.2) (0.8, 1.4) (1.2, 1.9) TRT difference³ — −0.4 −0.6−1.1 P value⁴ — 0.1269 0.0102 <0.0001 ¹P value calculated using atwo-sample t-test to compare Combo to Vehicle and to the individualcomponents. ²P value calculated using a Wilcoxon rank sum test tocompare Combo to Vehicle and to the individual components. ³TRTdifference: difference in the LS means (Combo LS mean − vehicle LS meanor component LS mean). ⁴P value from the ANCOVA analysis, with treatmentand baseline score (Visit 4A pre-CAC) as covariates, comparing Combo tovehicle and to its individual components. Source Table 14.2.6.2

TABLE 30 Ciliary Redness, Visit 3, 15-min Onset of Action, PP PopulationGroup 1.1.1.1.62 Cetirizine Fluticasone 1.1.1.1.63 Vehicle 1.1.1.1.61Combo 0.1% 0.005% 1.1.1.1.64 Time Point (N = 21) (N = 21) (N = 20) (N =21) Pre-CAC N 18 17 17 17 mean (SD) 0.39 (0.335) 0.59 (0.423) 0.59(0.374) 0.51 (0.576) 7 min post-CAC N 18 17 17 17 mean (SD) 1.44 (0.898)1.84 (0.852) 2.35 (0.834) 2.37 (0.857) P value¹ — 0.1921 0.0039 0.0038 Pvalue² — 0.1313 0.0054 0.0065 15 min post CAC N 18 17 17 17 mean (SD)1.89 (0.956) 2.25 (0.940) 2.47 (0.865) 2.54 (0.880) P value¹ — 0.26790.0677 0.0424 P value² — 0.2962 0.0711 0.0484 20 min post-CAC N 18 17 1717 mean (SD) 1.94 (1.100) 2.29 (0.953) 2.51 (0.946) 2.56 (0.788) Pvalue¹ — 0.3214 0.1090 0.0658 P value² — 0.2817 0.1196 0.0738 ANCOVA LSmean    1.77 2.04 2.40 2.47 95% CI (1.36, 2.18) (1.63, 2.46) (1.99,2.82) (2.05, 2.88) TRT difference³ — −0.27 −0.63 −0.70 P value⁴ — 0.35580.0348 0.0189 ¹P value calculated using a two-sample t-test to compareCombo to Vehicle and to the individual components. ²P value calculatedusing a Wilcoxon rank sum test to compare Combo to Vehicle and to theindividual components. ³TRT difference: difference in the LS means(Combo LS mean − vehicle LS mean or component LS mean). ⁴P value fromthe ANCOVA analysis, with treatment and baseline score (Visit 3 pre-CAC)as covariates, comparing Combo to vehicle and to its individualcomponents. Source Table 14.2.3.2

TABLE 31 Ciliary Redness, Visit 4A, 16-hr Duration of Action, PPPopulation Group 1.1.1.1.66 Cetirizine Fluticasone 1.1.1.1.67 Vehicle1.1.1.1.65 Combo 0.1% 0.005% 1.1.1.1.68 Time Point (N = 21) (N = 21) (N= 20) (N = 21) Pre-CAC N 18 17 17 17 mean (SD) 0.56 (0.359) 0.75 (0.451)0.63 (0.344) 0.79 (0.532) 7 min post-CAC N 18 17 17 17 mean (SD) 1.38(0.577) 1.81 (0.616) 1.71 (0.626) 2.03 (0.499) P value¹ — 0.0393 0.11430.0011 P value² — 0.0499 0.0893 0.0026 15 min post CAC N 18 17 17 17mean (SD) 1.51 (0.578) 1.90 (0.600) 1.84 (0.712) 2.10 (0.434) P value¹ —0.0633 0.1506 0.0017 P value² — 0.0494 0.0731 0.0018 20 min post-CAC N18 17 17 17 mean (SD) 1.53 (0.629) 1.91 (0.637) 1.72 (0.667) 2.04(0.461) P value¹ — 0.0823 0.3860 0.0092 P value² — 0.0889 0.3558 0.0122ANCOVA LS mean    1.48 1.85 1.71 2.04 95% CI (1.21, 1.74) (1.58, 2.12)(1.44, 1.98) (1.77, 2.31) TRT difference³ — −0.38 −0.23 −0.57 P value⁴ —0.0551 0.2294 0.0043 ¹P value calculated using a two-sample t-test tocompare Combo to Vehicle and to the individual components. ²P valuecalculated using a Wilcoxon rank sum test to compare Combo to Vehicleand to the individual components. ³TRT difference: difference in the LSmeans (Combo LS mean − vehicle LS mean or component LS mean). ⁴P valuefrom the ANCOVA analysis, with treatment and baseline score (Visit 3pre-CAC) as covariates, comparing Combo to vehicle and to its individualcomponents. Source Table 14.2.3.2

TABLE 32 Ciliary Redness, Visit 4B, 8-hour Rechallenge, PP PopulationGroup 1.1.1.1.70 Cetirizine Fluticasone 1.1.1.1.71 Vehicle 1.1.1.1.69Combo 0.1% 0.005% 1.1.1.1.72 Time Point (N = 21) (N = 21) (N = 20) (N =21) Pre-CAC N 18 17 17 17 mean (SD) 0.57 (0.444) 0.79 (0.478) 0.53(0.341) 0.97 (0.413) 7 min post-CAC N 18 17 17 17 mean (SD) 1.04 (0.759)1.65 (0.673) 1.68 (0.557) 2.01 (0.437) P value¹ — 0.0176 0.0080 0.0001 Pvalue² — 0.0177 0.0107 0.0003 15 min post CAC N 18 17 17 17 mean (SD)1.08 (0.702) 1.69 (0.693) 1.74 (0.603) 2.18 (0.393) P value¹ — 0.01460.0058 <0.0001 P value² — 0.0158 0.0061 0.0001 20 min post-CAC N 18 1717 17 mean (SD) 1.15 (0.713) 1.63 (0.650) 1.68 (0.717) 2.10 (0.566) Pvalue¹ — 0.0453 0.0377 0.0001 P value² — 0.0487 0.0463 0.0004 ANCOVA LSmean    1.11 1.63 1.67 2.06 95% CI (0.82, 1.41) (1.34, 1.93) (1.37,1.97) (1.77, 2.36) TRT difference³ — −0.52 −0.56 −0.95 P value⁴ — 0.01610.0101 <0.0001 ¹P value calculated using a two-sample t-test to compareCombo to Vehicle and to the individual components. ²P value calculatedusing a Wilcoxon rank sum test to compare Combo to Vehicle and to theindividual components. ³TRT difference: difference in the LS means(Combo LS mean − vehicle LS mean or component LS mean). ⁴P value fromthe ANCOVA analysis, with treatment and baseline score (Visit 3 pre-CAC)as covariates, comparing Combo to vehicle and to its individualcomponents. Source Table 14.2.3.2

TABLE 33 Ear or Palate Pruritis, Visit 3, 15-min Onset of Action, PPPopulation Group 1.1.1.1.74 Cetirizine Fluticasone 1.1.1.1.75 Vehicle1.1.1.1.73 Combo 0.1% 0.005% 1.1.1.1.76 Time Point (N = 21) (N = 21) (N= 20) (N = 21) Pre-CAC N 18 17 17 17 mean (SD) 0.1 (0.24) 0.3 (0.59) 0.2(0.53) 0.0 (0.00) 7 min post-CAC N 18 17 17 17 mean (SD) 0.4 (0.78) 0.3(0.59) 0.5 (0.94) 1.2 (1.39) P value¹ — 0.6859 0.6350 0.0372 P value² —0.7953 0.8031 0.0613 15 min post CAC N 18 17 17 17 mean (SD) 0.4 (0.85)0.6 (0.93) 0.7 (1.10) 1.4 (1.33) P value¹ — 0.3988 0.3509 0.0118 Pvalue² — 0.2771 0.3726 0.0101 20 min post-CAC N 18 17 17 17 mean (SD)0.6 (1.04) 0.8 (0.90) 1.0 (1.27) 1.5 (1.42) P value¹ — 0.6429 0.33140.0379 P value² — 0.3846 0.3593 0.0283 ANCOVA LS mean   0.6 0.4 0.7 1.595% CI (0.1, 1.0) (−0.1, 0.8) (0.3, 1.2) (1.1, 2.0) TRT difference³ —0.2 −0.2 −0.9 P value⁴ — 0.5701 0.6294 0.0034 ¹P value calculated usinga two-sample t-test to compare Combo to Vehicle and to the individualcomponents. ²P value calculated using a Wilcoxon rank sum test tocompare Combo to Vehicle and to the individual components. ³TRTdifference: difference in the LS means (Combo LS mean − vehicle LS meanor component LS mean). ⁴P value from the ANCOVA analysis, with treatmentand baseline score (Visit 4A pre-CAC) as covariates, comparing Combo tovehicle and to its individual components. Source Table 14.2.10.2

TABLE 34 Ear or Palate Pruritis, Visit 4A, 16-hr Duration of Action, PPPopulation Group 1.1.1.1.78 Cetirizine Fluticasone 1.1.1.1.79 Vehicle1.1.1.1.77 Combo 0.1% 0.005% 1.1.1.1.80 Time Point (N = 21) (N = 21) (N= 20) (N = 21) Pre-CAC N 18 17 17 17 mean (SD) 0.2 (0.73) 0.2 (0.56) 0.1(0.24) 0.4 (0.61) 7 min post-CAC N 18 17 17 17 mean (SD) 0.4 (0.85) 0.4(0.62) 0.4 (0.87) 1.5 (1.33) P value¹ — 0.9277 0.9378 0.0057 P value² —0.5321 0.9463 0.0023 15 min post CAC N 18 17 17 17 mean (SD) 0.7 (1.13)1.3 (0.99) 0.6 (1.11) 1.5 (1.37) P value¹ — 0.1191 0.8441 0.0677 Pvalue² — 0.0930 0.9377 0.0458 20 min post-CAC N 18 17 17 17 mean (SD)0.7 (1.08) 1.2 (1.03) 0.9 (1.43) 1.5 (1.23) P value¹ — 0.1216 0.52980.0355 P value² — 0.0737 0.6064 0.0240 ANCOVA LS mean   0.6 0.7 0.6 1.695% CI (0.2, 1.1) (0.3, 1.2) (0.2, 1.1) (1.2, 2.1) TRT difference³ —−0.1 0.0 −1.0 P value⁴ — 0.7055 0.9348 0.0024 ¹P value calculated usinga two-sample t-test to compare Combo to Vehicle and to the individualcomponents. ²P value calculated using a Wilcoxon rank sum test tocompare Combo to Vehicle and to the individual components. ³TRTdifference: difference in the LS means (Combo LS mean − vehicle LS meanor component LS mean). ⁴P value from the ANCOVA analysis, with treatmentand baseline score (Visit 4A pre-CAC) as covariates, comparing Combo tovehicle and to its individual components. Source Table 14.2.10.2

TABLE 35 Ear or Palate Pruritis, Visit 4B, 8-hour Rechallenge, PPPopulation Group 1.1.1.1.82 Cetirizine Fluticasone 1.1.1.1.83 Vehicle1.1.1.1.81 Combo 0.1% 0.005% 1.1.1.1.84 Time Point (N = 21) (N = 21) (N= 20) (N = 21) Pre-CAC N 18 17 17 17 mean (SD) 0.2 (0.65) 0.2 (0.56) 0.2(0.73) 0.3 (0.47) 7 min post-CAC N 18 17 17 17 mean (SD) 0.3 (0.69) 0.7(0.85) 0.6 (1.06) 1.2 (1.24) P value¹ — 0.1648 0.4099 0.0206 P value² —0.1409 0.4419 0.0213 15 min post CAC N 18 17 17 17 mean (SD) 0.4 (0.78)1.1 (1.05) 0.8 (1.24) 1.2 (1.15) P value¹ — 0.0412 0.2915 0.0250 Pvalue² — 0.0366 0.3785 0.0256 20 min post-CAC N 18 17 17 17 mean (SD)0.5 (0.86) 1.2 (1.01) 0.8 (1.20) 1.3 (1.16) P value¹ — 0.0416 0.46120.0292 P value² — 0.0227 0.4933 0.0246 ANCOVA LS mean   0.5 0.8 0.6 1.495% CI (0.1, 0.9) (0.4, 1.2) (0.2, 1.1) (0.9, 1.8) TRT difference³ —−0.3 −0.2 −0.9 P value⁴ — 0.2954 0.5919 0.0036 ¹P value calculated usinga two-sample t-test to compare Combo to Vehicle and to the individualcomponents. ²P value calculated using a Wilcoxon rank sum test tocompare Combo to Vehicle and to the individual components. ³TRTdifference: difference in the LS means (Combo LS mean − vehicle LS meanor component LS mean). ⁴P value from the ANCOVA analysis, with treatmentand baseline score (Visit 4A pre-CAC) as covariates, comparing Combo tovehicle and to its individual components. Source Table 14.2.10.2

Secondary Efficacy Endpoints (Diary Data)

During the 12 days between Visits 3 and 4A, subjects self-administeredstudy medication QD and rated their ocular and nasal symptoms in themorning and in the evening using a 5-point scale (0 to 4, where0=None/Absent; 1=Mild; 2=Moderate; 3=Severe; and 4=Very Severe). Table36 shows an overview of the diary data analysis (ANCOVA). The numberswithin cells in Table 36 represent the treatment difference calculatedwith the ANCOVA model, which included both morning and evening data fromall 12 days of diary data.

-   -   Combo demonstrated significantly lower (P<0.05) scores than        vehicle for ocular itching, lid swelling, tearing/watery eyes,        nasal itching, nasal congestion, rhinorrhea, ear/palate itching,        and total nasal symptom scores (TNSS).    -   Combo arm had lower scores than vehicle for ocular redness        (statistical trend)    -   The ocular itching data from the diary scores, while not        reaching the level of clinical efficacy, showed the same trend        as was observed in the CAC data. The diary data represent        subjects' response to environmental allergens and tend to        validate the modified CAC model.

TABLE 36 Diary Data: Overall Results for all Treatments vs Vehicle

-   -   Combo demonstrated clinical efficacy in the prevention of        ciliary redness at Visit 4B. The mean ciliary redness scores for        Combo were significantly lower (P<0.05) than vehicle at all 3        time points at Visit 4B. The treatment differences (Combo mean        minus Vehicle mean) at Visit 4B were −0.97, −1.1, and −0.95        units at 7, 15, and 20 minutes post CAC, respectively. At Visit        3, 2 of 3 time points were significantly lower (P<0.05) than        Vehicle. At Visit 4A, all 3 time points were significantly lower        than Vehicle, but the magnitudes of the treatment differences        were not greater than 1.0 unit at any of the 3 time points. See        Tables 30-32 for the detailed ciliary redness data in the PP        population at Visits 3, 4A, and 4B, respectively.    -   Combo demonstrated clinical efficacy in the prevention of        ear/palate itching at Visit 4A. The mean ear/palate itching        scores for Combo were significantly lower (P<0.05) than vehicle        at all 3 time points at Visit 4A. The treatment differences        (Combo mean minus Vehicle mean) at Visit 4A were −1.1, −0.8, and        −0.8 units at 7, 15, and 20 minutes post CAC, respectively. The        treatment difference from the ANCOVA model was −1.0 units. At        Visits 3 and 4B, all 3 time points were significantly lower        (P<0.05) than Vehicle. At Visits 3 and 4B, the magnitudes of the        treatment differences were all greater than 0.5 units, but the        majority were <1.0 unit. See Tables 33-35 for the detailed        ear/palate itching data in the PP population at Visits 3, 4A,        and 4B, respectively.    -   Combo demonstrated significant lower (P<0.05) scores for        episcleral redness, tearing/watery eyes, rhinorrhea, and nasal        congestion compared to Vehicle. See Table 16 for the overview.

All efficacy analyses were performed on data collected at Visits 3, 4A,and 4B. Primary and secondary efficacy analyses were performed on boththe ITT population and the PP population.

ITT population: Eighty three (83) subjects were randomized at Visit 2Band comprised the ITT population. No subjects were excluded from the ITTpopulation because of protocol violations. The ITT population wasanalyzed as randomized; all data were included. Missing data wereimputed using the last observation carried forward method (LOCF) for theITT population.PP Population: The PP population was a subset of the ITT population andconsisted of subjects who completed all four visits with no majorprotocol violations. This population was analyzed as treated usingobserved data only and was used for confirmatory analyses. Fourteen (14)subjects in the ITT population were excluded from the PP population; 12of these subjects did not complete the study. The reasons fordiscontinuation included: subject noncompliance (missed study visit, ordid not return study drug or diary, n=9); tech error: subject givenwrong drug (n=2), or subject should have screen failed at Visit 1 (n=1).All safety analyses were performed on the safety population.Safety population: The Safety population included all randomizedsubjects who received at least one dose of any investigationaltreatment. All 83 subjects randomized at Visit 2B also received theirfirst dose of assigned study medication post CAC at Visit 2B, and thuscomprise the Safety population. The Safety population was analyzed astreated; no data exclusion was allowed for any reason.

Conclusion

The low dose combination of 0.1% Cetirizine/0.005% Fluticasone was themost effective at preventing signs of allergic conjunctivitis in thehuman modified conjunctival allergen challenge (CAC) compared tocomponents of the combination used alone at the same concentration.

The data described herein demonstrate clinical and statisticalsuperiority of the combination of 0.1% Cetirizine/0.005% Fluticasone.The combination had clinically and statistically significant loweritching scores and conjunctival redness scores than vehicle at allvisits and timepoints. The combination was statistically superior tocetirizine in the prevention of conjunctival redness (Visit 4B at alltimepoints). The combination was statistically superior to fluticasonein the prevention of ocular itching (Visit 3 and Visit 4B) and in theprevention of conjunctival redness (Visit 3 and Visit 4B)

The combination also had statistically significantly lower scores thanvehicle for ocular itching, lid swelling, tearing/watery eyes, nasalitching, nasal congestion, rhinorrhea, ear/palate itching, and totalnasal symptom scores surprisingly, even though the concentrations weremuch lower than that used for currently marketed nasal preparations offluticasone

Additionally, at 0.005% Fluticasone did not contribute to elevatedintraocular pressure (IOP) as one may have expected from ocularadministration of a steroid, yet a dose of the active ingredients wasidentified that was highly efficacious with only QD dosing.

Lastly, the low dose combination worked better than well known; leadingocular antihistamine and ocular steroid—these results confirm theeffectiveness of the specific combination of cetirizine/fluticasone atthe preferred low dose concentrations.

EQUIVALENTS

Those skilled in the art will recognize, or be able to ascertain usingno more than routine experimentation, many equivalents to the specificembodiments of the invention described herein. Such equivalents areintended to be encompassed by the following claims.

We claim:
 1. A topical ophthalmic formulation comprising about 0.1%cetirizine (w/v) or a pharmaceutically acceptable salt thereof and about0.005% fluticasone (w/v).
 2. The ophthalmic formulation of claim 1,wherein the fluticasone is present as fluticasone propionate.
 3. Theophthalmic formulation of claim 1, wherein the cetirizine is present ascetirizine hydrochloride or dihydrochloride.
 4. The ophthalmicformulation of claim 1, further comprising glycerin.
 5. The ophthalmicformulation of claim 4, wherein the glycerin is at a concentration of0.1% to 3% (v/v).
 6. The ophthalmic formulation of claim 1, furthercomprising a preservative.
 7. The ophthalmic formulation of claim 6,wherein the preservative is benzalkonium chloride or a derivativethereof, or a stabilized, oxychloro complex.
 8. The ophthalmicformulation of claim 7, wherein the preservative is benzalkoniumchloride present in amount ranging from 0.005% to 0.02% (v/v).
 9. Theophthalmic formulation of claim 1, wherein the pH of the composition isabout 5.0 to 8.0.
 10. The ophthalmic formulation of claim 1, wherein theformulation is an aqueous formulation, an ointment, oil, a suspension,an emulsion, or incorporated in a drug delivery device.
 11. Theophthalmic formulation of claim 9, wherein the formulation is in anaqueous formulation.
 12. The ophthalmic formulation of claim 1, whereinthe cetirizine is in solution and the Fluticasone is in suspension. 13.A topical ophthalmic formulation comprising 0.1% cetirizine (w/v),0.005% fluticasone (w/v), 1% Polyethylene Glycol 400, NF, 0.2% DibasicSodium Phosphate, Anhydrous, USP, 0.25% Hypromellose, USP, 0.1%Polysorbate 80, NF, 1.8% Glycerin, USP, 0.025% Edetate Disodium, USP,0.01% Benzalkonium Chloride, NF.
 14. The formulation of claim 13,wherein the pH is about 5.0-8.0
 15. The formulation of claim 13, whereinthe pH is 7.0.
 16. A method of treating a sign or symptom of an allergicdisorder by topically administering to the eye of a subject in need ofsuch treatment the ophthalmic formulation of claim
 1. 17. The method ofclaim 16, wherein the allergic disorder is against an airborne allergen.18. The method of claim 16, wherein the allergic disorder is an ocularallergy or a nasal allergy.
 19. The method of claim 16, wherein the signor symptom is selected from the group comprising, ocular itching,redness, lid swelling, chemosis, tearing rhinorrhea, sneezing, nasalcongestion, nasal itching, itching of the palate, or itching of the earitching, redness, lid swelling, chemosis, tearing rhinorrhea, sneezing,nasal congestion, nasal itching, itching of the palate, or itching ofthe ear.
 20. The method of claim 16, wherein the allergic disorder isallergic conjunctivitis, allergic rhinoconjunctivitis or rhinitis
 21. Amethod for treating a sign or a symptom of allergic conjunctivitis bytopically administering to the eye of a subject in need of suchtreatment the ophthalmic formulation of claim
 1. 22. The method of claim21, wherein said sign and symptom is selected from the group consistingof ocular itching, redness, lid swelling, chemosis or tearing.
 23. Amethod for treating a sign or a symptom of allergic rhinoconjunctivitisby topically administering to the eye of a subject in need of suchtreatment the ophthalmic formulation of claim
 1. 24. The method of claim23, wherein said sign and symptom is selected from the group consistingof ocular itching, redness, lid swelling, chemosis, tearing, rhinorrhea,sneezing, nasal congestion, nasal itching, itching of the palate, oritching of the ear.
 25. A method for treating a sign or a symptom ofrhinitis by topically administering to the eye of a subject in need ofsuch treatment the ophthalmic formulation of claim
 1. 26. The method ofclaim 25, wherein said sign and symptom is selected from the groupconsisting of rhinorrhea, sneezing, nasal congestion, nasal itching,itching of the palate, or itching of the ear.
 27. The method of claim16, wherein the ophthalmic formulation is administered once or twicedaily.